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.

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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