Actual Nursing Care Plan 2
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Transcript of Actual Nursing Care Plan 2
ACTUAL NURSING CARE PLAN #1
ASSESSMENT
NURSING DIAGNOSI
SOBJECTIVES
IDEALINTERVENTION
ACTUALINTERVENTION
RATIONALEEVALUATION
Subjective cues:“dugay2x naman ni akong samad ma’am , ga.katol sya sa kilid, dli pd sya sakit kani lang sa gahi kung e.duot. Naa sa 3/10 ma’am, makaya-kaya ra man.” As verbalized.
Objective cues:
Disruption of skin surface at the R upper arm
Dry
Impaired skin integrity related to inflammatory response secondary to infection
Short Term:
At the end of 8 hours of nursing care, patient will be able to:
Verbalize understanding of skin care regimen
Verbalize relief of discomfort
Verbalize understanding of the importance of caring the infected wound
Participate in prevention measures and
Independent: Independent:
1. Examined the skin for open wounds, discoloration. Described and measured wound and observed changes.
2. Educated patient proper skin hygiene such as washing thoroughly and pat dry carefully.
3. Inspected the
1. Provides information regarding skin circulation and problems that caused by application of dressing. Establishes comparative baseline providing opportunity for timely intervention.
2. Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of
Short Term:
At the end of 2-4 hours of nursing care, patient has been able to:
Demonstrate ways and technique on how to reduce pain to a tolerable level.
Follow prescribed pharmacological regimen.
Verbalize understanding of pain managemen
open wound @ 7cm in diameter
Localized erythema surrounding the wound
Edematous surrounding areas
Localized heat
Pustule noted with small amount of reddish discharges surrounding the areas
With some purulent
treatment program
Long Term:
At the end of 25 hours of nursing care, patient will be able to:
Exhibit no further skin breakdown
Maintain wound intact
Minimize redness on the surrounding area
Display improvement on wound as evidenced by absence of some purulent discharges, absence of
wound every shift using FREEDA (redness, edema, ecchymosis, discharge and approximation).
4. Emphasized the importance of adequate nutrition and fluid intake.
5. Provided and applied wound care and dressing carefully.
6. Encouraged adequate hydration and nutrition.
7. Educate patient on the importance of keeping the skin clean and dry.
dermal trauma to fragile skin.
3. Frequent assessment can detect early signs and symptoms of further infection.
4. Improved nutrition and hydration will improve skin condition.
5.
6. Adequate hydration and nutrition helps maintain skin turgor and suppleness.
7. Moisture softens the skin and causes a break in the skin integrity.
t
Long Term:
At the end of 24 hours of nursing care, patient will be able to:
Know and perform activities that do not only provide relief from pain but helpful in dealing the disease condition.
Has not been able to:
Verbalize relief of pain from a
discharges
(+) pruritus on the surrounding of the wound
itchiness8. Kept area clean
and dry, support incision (splinting when couching).
9. Repositioned patient on regular schedule, involving patient in reasons for and decisions about times and positions.
10. Encouraged and assisted early ambulation or mobilization.
Collaborative:
1. Administered antibiotic, as indicated.
Cefuroxime
8. To assist body’s natural process of repair.
9. To enhances understanding and cooperation.
10. Promotes circulation and reduces risks associated with mobility.
1. To facilitate prophylaxis of possible infection.
To inhibit synthesis of bacterial
scale of 8/10 to 3-5/10
750mg 1 vial Q12˚
2. Administered replacement of fluids and electrolytes.
cell wall causing cell death.
2. To support circulating volume and tissue perfusion.
ACTUAL NURSING CARE PLAN #2
ASSESSMENT NURSING DIAGNOSIS
OBJECTIVES INTERVENTION RATIONALEEVALUATION
Subjective cues:“Init man akong paminaw ma’am.” As verbalized
Objective cues: T: 37.9˚C
/axilla Flushed
skin Warm to
touch Good skin
turgor appropriate to age
Hyperthermia related to increased metabolic activity as evidenced by elevated temperature
Short Term:
At the end of 4 hours of nursing care, patient will be able to:
Return to normal temperature within normal range
Maintain good skin turgor
Long Term:
At the end of 24 hours of nursing care, patient will be able to:
Demonstrate behaviors to
Independent:
1. Monitored temperature every 2 hours.
2. Provided tepid sponge baths.
3. Monitored vital signs.
4. Monitored signs of
1. Knowing the temperature of the body.
2. Tepid sponge bath may help reduce fever. Note: use of ice water or alcohol may cause chills, actually elevating temperature. Alcohol can also cause skin dehydration.
3. Effect of temperature increase is a change in pulse, respiration and blood pressure.
Short Term:
At the end of 4 hours of nursing care, patient has been able to:
Return to normal temperature within normal range, from 37.9˚C to 37.3˚C
Maintain good skin turgor
Long Term:
At the end of 24 hours of nursing care, patient has been able to:
Demonstrate behaviors to
monitor and promote normothermia
dehydration.
5. Evaluated skin turgor, capillary refill.
6. Encouraged and instructed patient to increase fluid intake up to 2000mL/day.
7. Instructed to maintain bed rest.
8. Discussed importance of adequate fluid
Collaborative:
1. Administered anti-pyretic, as indicated.
4. The body can lose water through the skin and evaporation.
5. To determine hydration and circulating volume.
6. To prevent dehydration.
7. To reduce metabolic demands and oxygen consumption.
8. To prevent dehydration.
monitor and promote normothermia
Paracetamol 500 mg 1 tab q4˚ RTC
2. Administered replacement of fluids and electrolytes.
1. To treat underlying cause, to control shivering.
Antipyretics reduce fever by its central action on the hypothalamus.
2. To support circulating volume and tissue perfusion.
ACTUAL NURSING CARE PLAN #3
ASSESSMENT NURSING DIAGNOSIS
OBJECTIVES INTERVENTION RATIONALEEVALUATION
Subjective cues:“sakit kayo e-ihi, naa sa 8 ang ka.sakit”
Objective cues: Pain scale =
8/10 upon urinating
Presence of FBC attached to urobag, draining bloody urine
Hematuria Urine
output per shift: 1000 - 1200mL
Impaired Urinary Elimination related to decreased renal perfusion, irritation of the kidney / ureter, inflammation, bladder stimulation by a stone secondary nephrolithiasis
Short Term:
At the end of 4 hours of nursing care, patient will be able to:
Verbalize understanding of condition
Long Term:
At the end of 24 hours of nursing care, patient will be able to:
Participate in measures to correct or compensate for defects
Maintain increase urine output
Independent:
1. Noted age and gender of the patient.
2. Examined the pain, noting location, duration, intensity; presence of bladder spasm; or back or flank pain.
3. Determined patient’s usual daily fluid intake. Noted condition of skin and mucous
1. Incontinence and urinary tract infection are more prevalent in women and older adults; painful bladder syndrome or interstitial cystitis is more common in women.
2. To assist in differentiating between bladder and kidney as cause of dysfunction.
3. To help determine level of hydration.
Short Term:
At the end of 4 hours of nursing care, patient has been able to:
Verbalize understanding of condition
Long Term:
At the end of 24 hours of nursing care, patient has been able to:
Participate in measures to correct or compensate for defects
Maintain increase urine
Reduce blood in the urine
membranes, color of urine.
4. Encouraged fluid intake up to 3000 mL/day, within tolerance.
5. Monitored intake and output and characteristics of urine.
6. Determined patient’s normal voiding pattern and noted variations.
7. Noted condition o
4. To help maintain renal function, and prevent infection; and to increase hydration to flushed bacteria.
5. To provide information about the kidney function and presence of complication.
6. Calculi may cause nerve excitability, which causes sensation of urgent need to void, usually frequency and urgency increase as calculus nears ureterovesical
output
Has not been able to
Reduce blood in the urine
skin and mucous membrane, color of urine.
8. Observed signs of infection.
9. Emphasized importance of having good hygiene.
10. Emphasized importance of adhering to treatment regimen.
junction.
7. To assess level of hydration.
8. To help in treating urinary alteration.
9. To promote wellness.
10. To promote wellness.
ACTUAL NURSING CARE PLAN #4
ASSESSMENT NURSING DIAGNOSIS
OBJECTIVES INTERVENTION RATIONALEEVALUATION
Subjective cues:(none)
Objective cues: Presence of
post-operative wound on R lumbar area and RLQ, status post nephrolithiasis
Good skin turgor appropriate to age
Capillary refill returns less than 2 seconds
Impaired Skin Integrity related to surgical incision, altered body temperature
Short Term:
At the end of 8 hours of nursing care, patient will be able to:
Verbalize understanding of skin care regimen
Verbalize relief of discomfort
Normalize skin turgor and capillary refill
Verbalize understanding of the importance of caring the incision site
Long Term:
Independent:
11. Examined the skin for open wounds, discoloration, blanching, and rashes.
12. Inspected the incision every shift using FREEDA (redness, edema, ecchymosis, discharge and approximation).
13. Encouraged and assisted posting of a turning schedule, restricting time in one position to 2 hours or less.
11. Provides information regarding skin circulation and problems that caused by application of dressing.
12. Frequent assessment can detect early signs and symptoms of infection.
13. To prevent discomfort and injuries to the body; to promote circulation.
Short Term:
At the end of 8 hours of nursing care, patient has been able to:
Verbalize understanding of skin care regimen
Verbalize relief of discomfort
Normalize skin turgor and capillary refill
Verbalize understanding of the importance of caring the incision site
Long Term:
At the end of 24
At the end of 24 hours of nursing care, patient will be able to:
Exhibit no further skin breakdown
Maintain wound intact
Display no redness on the surrounding area or signs of inflammation
14. Encouraged S.O to maintain functional body alignment of the patient like positioning it properly.
15. Encouraged adequate hydration and nutrition.
16. Educate patient on the importance of keeping the skin clean and dry.
17. Kept area clean and dry, support incision (splinting when couching).
18. Repositioned patient on regular schedule, involving patient in reasons for and decisions
14. Misalignment can lead to discomfort and injuries to joints, limbs or nerves.
15. Adequate hydration and nutrition helps maintain skin turgor and suppleness.
16. Moisture softens the skin and causes a break in the skin integrity.
17. To assist body’s natural process of repair.
18. To enhances understanding and
hours of nursing care, patient has been able to:
Exhibit no further skin breakdown
Maintain wound intact
Display no redness on the surrounding area or signs of inflammation
about times and positions.
19. Encouraged and assisted early ambulation or mobilization.
Collaborative:
3. Administered antibiotic, as indicated.
Cefuroxime 750mg 1 vial Q12˚
4. Administered replacement of fluids and electrolytes.
cooperation.
19. Promotes circulation and reduces risks associated with mobility.
3. To facilitate prophylaxis of possible infection.
To inhibit synthesis of bacterial cell wall causing cell death.
4. To support
circulating volume and tissue perfusion.
ACTUAL NURSING CARE PLAN #5
ASSESSMENT NURSING DIAGNOSIS
OBJECTIVES INTERVENTION RATIONALEEVALUATION
Subjective cues:(none)
Objective cues: Presence
of post-operative wound on R lumbar area and RLQ, status post nephrolithiasis
T: 37.9˚C
Risk for Infection related to inadequate primary defenses – break in skin or post surgical incision
Short Term:
At the end of 8 hours of nursing care, patient will be able to:
Verbalize understanding of individual causative or risk factor(s)
Demonstrate techniques, lifestyle changes to promote safe environment
Identify interventions to prevent or
Independent:
1. Monitored vital signs.
2. Assesses signs and symptoms of infection especially temperature.
3. Maintain hydration and voiding schedule.
1. An elevated temperature suggests incisional infection, urinary tract infection or respiratory complications.
2. Fever may indicate infection.
3. To prevent bladder distention and urinary stasis which can contribute to the multiplication of
Short Term:
At the end of 8 hours of nursing care, patient has been able to:
Verbalize understanding of individual causative or risk factor(s)
Demonstrate techniques, lifestyle changes to promote safe environment
Identify interventions to prevent or
reduce risk of infection
Maintain or normalize temperature within normal range
Long Term:
At the end of 24 hours of nursing care, patient will be able to:
Verbalize full knowledge in identifying risk factors of infection.
Be free from any signs and symptoms related to infection
4. Emphasized the importance of hand washing technique.
5. Maintained aseptic technique when changing dressing and/or caring wound.
6. Kept area around wound clean and dry.
7. Discussed the importance of not taking antibiotics unless specifically instructed by health care provider.
pathogens.
4. It serves as a first line of defense against infection.
5. Regular wound dressing promotes fast healing and drying of wounds.
6. Wet area can be lodge area f bacteria.
7. Inappropriate use can lead to development of drug-resistant strains or secondary infections.
reduce risk of infection
Maintain or normalize temperature within normal range (37.3˚C)
Long Term:
At the end of 24 hours of nursing care, patient has been able to:
Verbalize full knowledge in identifying risk factors of infection.
Be free from any signs and symptoms related to infection
Collaborative:
1. Administered antibiotic, as indicated.
Cefuroxime 750mg 1 vial Q12˚
2. Administered replacement of fluids and electrolytes.
\
1. To facilitate prophylaxis of possible infection.
To inhibit synthesis of bacterial cell wall causing cell death.
2. To support circulating volume and tissue perfusion