Professional Documents
Culture Documents
Chapter One
Chapter One
ON
MRS G.A.
WITH
INTESTINAL OBSTRUCTION SECONDARY TO POST OPERATIVE ADHESIONS
(BOWEL RESECTION AND ANASTAMOSIS DONE)
PRESENTED BY
CHAPTER ONE
ASSESSMENT OF PATIENT AND FAMILY
Assessment of patient and family is the first step in the nursing process which involves a careful
and systematic collection of data from the patient, family, friends and community through
examination, observation, interview, laboratory investigations and x-ray
The purpose of this study is to identify the patients problem which is expresseds as actual or
potential. The information serves as a foundation upon which appropriate nursing intervention
will be established and implemented for the speedy recovery of the patient.
PATIENTS PARTICULARS
Mrs. G.A. is a 68year-old woman born on 11th March 1946 to Opanin Kofi Boakye and Maame
Yaa Nsia; who are both deceased. dead and may their soul rest in perfect peace; on 11th March
1946 at Oduom in the Ashanti Region of Ghana. She is dark in complexion and stays at
Nyankyirenease. Mrs G. A. is about 5.2 feet tall and weighs about 52kg. She is the third (3rd)
among eleven (11) siblings, and the only female. She was married to O. A. Opanin Akwasi Prah
and have givenave birth to nine (9) children; five(5) male and four(4) female. Two females are
deceased. and two(2) among the four (4) females are dead. She is a Christian and worships with
the Methodist Church at Nyankyirenease
Next of kin?
According to Mrs. G.A. there is no known chronic or hereditary diseases like hypertension,
asthma, or mental illness in the family. diabetes mellitus and also no known history of mental
illness and communicable disease like tuberculosis, leprosy, epilepsy in their family. She also
could not remember any food allergies. admitted that there are no food allergies. Members of the
family usually take over- the- counter drugs to cure treat minor illness like malaria, headache and
, bodilty pains, etc. She depends on her grown children for financial support.
Type of accommodation?
Is she employed or what was the previous job
Source of drinking water
Refuse disposal
Economic class???
PATIENTS DEVELOPMENTAL HISTORY
According to client, she was born at term by spontaneous vaginal delivery with the help of a
Ttraditional Bbirth Aattendant (TBA) at home. Clients mother then sent her to a nearby clinic
for other treatment. Client went through a normal developmental milestone without any
complains. . She began teething at age 5 months, started to crawl at age 9 months and started
walking at age 14 months. She feeds on the normal family diet such as fufu and light soup, rice
and stew, banku and okra stew or palm nut soup.
Your developmental history must contain the following (you have already written some)
a.
b.
c.
d.
e.
f.
Immunisation status
B.feeding history
Developmental milestone; summary
Educational history
Secondary sexual characteristics
Marital history if married
Mrs. G.A .usually wakes up at 5:30 a.m. and says a word of prayer before getting up from bed.
She washes her his face, brushes her teeth with tooth paste and tooth brush then shower down.
She then takes in breakfast. She then goes out to take a walk and comes back to the house to
watch television then sleeps when feeling tired. . She normally takes her supper at 6:30pm. She
watches television, maintains her personal hygiene and goes to bed at 9pm. According client, she
baths twice daily with soap, sponge and warm water. She cleans her teeth twice daily with
toothpaste and brush before and after going to bed. She empties her bowel twice daily.
ADMISSION OF PATIENT
On Friday, 10th October 2014 at 7:25am, Mrs. G.A. was admitted through the Accident and
Emergency Centre (Major and Minor) of Komfo Anokye Teaching Hospital to the Female
Surgical Ward C4. She was brought to the ward on a trolley fully conscious accompanied by a
triage nurse and three relatives, with about 250mls of dextrose saline in situ and , dripping were.
There was also urethral catheter and nasogastric tube in situ. She came to the ward with the
following medications; IV Augumentin 2g stat, Injection Pethedine 10mg stat, IV Flaggyl, IV
Ciprofloxacin, IV Normal Saline and IV Dextrose Saline. They were warmly welcomed and
escorted to the nurses table. Her relatives were given a chair near the nurses table to assist in
providing information about the patient. Clients folder was collected from the accompanying
nurse. She was placed in a recumbent position in a comfortable bed free from creases and
crumbs. Client and relatives were reassured of good medical and nursing intervention and care.
The information about the client in the admission papers was read to gain knowledge about the
patient, her particulars such as name, sex, age, date and time of admission were identified and
recorded. The patients name and other information were entered in the Admission and Discharge
book and daily ward state. Vital signs were checked and recorded as follows:
Temperature = 37.5 C.
Pulse
Respiration
Comments
I think your admission is poorly done. You failed to:
Patient has no knowledge about the cause, signs and symptoms, treatment or prevention of
intestinal obstruction. She did not attribute it to spiritual forces but believe it is a natural
occurrence. She was worried about the outcome of her condition. She was however reassured not
to be intimidated and that the treatment she was is receiving will help her to recover.
A. MECHANICAL BLOCKAGE
Factors that cause mechanical blockage are divided into three.
1. Condition that occur within the intestinal lumen(intramural) such as;
Fecal impaction
Intussusceptions.
Stenosis.
Polyps.
Strangulated hernia.
Volvulus.
Muscular dystrophy
Paralytic ileus.
Obstruction in the upper intestine results in metabolic alkalosis from dehydration and loss of
gastric hydrochloric acid.
Obstruction in the lower intestines causes slower dehydration and loss of intestinal alkaline fluid
resulting in metabolic acidosis. Ultimately, intestinal obstruction may lead to ischemia, necrosis
and death.
CLINICAL FEATURES.
1) Colicky pains in the abdomen.
2) Nausea
3) Vomiting (vomiting of fecal contents at times.)
4) Constipation
5) Distended abdomen
6) Abdominal tenderness
7) Dehydration with electrolyte loss
8) Sunken eyes
9) Hollow checks
10) Dry skin
11) Septic absorption
12) High pulse rate
13) Cold clammy skin
14) Pallor
15) Delirium in severe cases.
COMPLICATIONS
1. Perforation
2. Peritonitis
3. Septicemia
4. Metabolic alkalosis or acidosis
5. Hypovolaemic shock
6. Death if untreated.
DIAGNOSTIC INVESTIGATION
1. Abdominal x rays confirm obstruction and reveals the presence and location of
intestinal gas fluid.
2. White blood cell count may be slightly normal if necrosis, peritonitis or strangulation
occurs.
3. Sigmoidoscopy, colonoscopy or barium enema may help determine the cause of
obstruction.
4. Hemoglobin concentration and haematocrit may increase indicating dehydration.
5. Serum sodium, chloride and potassium level may fall because vomiting.
6. Serum amylase level may increase possibly from irritation of the pancreas by distended
abdomen.
7. Physical exams may reveal distended abdomen.
8. History from the patient.
9. Signs and symptoms.
Psychological Care
Reassure the client and the relative by explaining the type of surgery to be done on her and the
disease condition make it known to her that she is in the hands of competent staff and so by her
complying with she will get well within few days. This will help to relieve her of anxiety and
fears. Introduce people who have undergone such operation to her. Allow her to ask any question
about her condition and this will help her gain knowledge about and understand her condition.
Rest and Sleep
Her bed should be free from crumbs and creases to prevent her being uncomfortable. Eliminate
noise at the ward; make sure all procedures are performed at a goal to prevent procedures
destructing her sleep.
Semi Fowlers position is the appropriate position she must be kept in this position as much as
possible to promote pulmonary ventilation and ease respiratory distress form abdominal
distension.
Observation
Vital signs such as temperature, pulse, respiration are observed every four hours while blood
pressure observed every hourly to serve as a baseline for evaluating whether the patients
condition is progressing or improving.
She must be observed for pain and monitor input and output chart, if abdomen is chastened,
abdominal girth is measured, patient must be weighed daily, her emotional state must be
observed and patient reassured site of intravenous fluids must be observed for bleeding, swatting,
blockage of the line and rate of flow to present any cardiac over load.
Side effects of drugs must be observed and recorded.
Pain relieve
Patient must be observed for pain and pain management given, diversional therapy may be done
to distract the patients mind from pain, and cold compresses may be applied at the site of
distension which can help relax the muscles. Patient must be encouraged to assume the position
she finds comfortable which is not contraindicated to her condition. Administration of preceded
analgesics such as diclofenac 100 mg must be given to relive pain.
Consent of Patient
After all the explanation necessary for the patient to gain knowledge, understand her surgery a
consent form is made to be signed by the patient and this gives the legal right for the operation to
be performed on the patients.
Investigation
All investigation must be done on the patent to correct any abnormalities related to blood,
hemoglobin estimation, white blood cell count, sickling, grouping and cross matching.
Nutrition
Serve fluid diet the night before the surgery. Intravenous fluids such as dextrose saline normal
saline, ringers lactate may be given to correct fluid and electrolyte loss. Nothing is given by
mouth on the morning of the operation.
Skin Preparation
The area to be shaved must be washed and dried shave from 3 inches above the nipple of the
breast to middle thigh including the pubic, clean the shaved area again with an antiseptic lotion.
Observation
Observe and monitor vital signs every thirty (30) minutes till patients condition subsides or
stabilizes. Monitor the intravenous fluids for blood clot in the needle, presence of air bubbles
tube kinked, all these are done to prevent the development of any complication, also type of
infusion, amount, time infusion was set up must be observed and recorded.
The number of drops per minute and time infusion was completed are all recorded in the input
and output chart. Vital signs that are temperature, pulse, respiration and blood pressure are also
checked for signs of complications like bleeding. Observe for cyanosis, if present, is a sign of
hypoxia.
Wound Care
Dressing are normally changed on the third day post operatively, wound dressing must be done
under aseptic technique. Alternate stitches are removed on the seventh day and remaining
stitches removed on the Tenth day after surgery. The removal of the stitches depends on the
condition of the wound and hospital policy. The wound must be observed for infection, bleeding
and pain.
Personal Hygiene
Oral toileting and bed bath needs to be done regularly to prevent harboring of microbes, thereby
preventing secondary infection.
Education
Education may be given based on the causes of intestinal obstruction, signs and symptoms of the
condition, the need for the surgical intervention preventive measures, the need for periodic
medical exams, the need to take drugs and for review
All these are given to direct and to equip her with the necessary information on intestinal
obstruction so that she can take the necessary precaution to prevent the condition from
reoccurring.
Drugs
Prescribed drugs such as pethedine 50 mg as prescribed may be given to patient to relieve pain.
Antibiotics may also be given to prevent secondary infections.
Desired and side effects of drugs must also be observed.
VALIDATION OF DATA
With reference to the data collected, signs and symptoms which patient presented are the actual
clinical features of intestinal obstruction as confirmed by the literature review of the condition.
Data collected from the client and relatives were cross checked with client's folder, laboratory
investigation and assessment.
Therefore, all these proved that client was suffering from intestinal obstruction secondary to
postoperative adhesions.
CHAPTER TWO
ANALYSIS OF DATA
Analysis of data is the interpretation of assessment data collected to identify patients specific
needs and strengths, which helps in the formulation of an appropriate nursing diagnoses. It
includes both actual and potential identified needs.
This consists of:
(a) Comparison of data with standards. This covers diagnostic investigations, causes, clinical
features, treatment, complications and pharmacology of drugs.
(b) Patient/ family strengths
(c) Health problems
(d) Nursing diagnosis.
DATE
SPECIMEN/
Body
10/10/14
INVESTIGATION
RESULTS
NORMAL VALUE
INTERPRETATION
REMARKS
Haemoglobin level
15.7 g/dl
Normal.
No
part
examined
Blood
eEstimation
treatment
given.
Patient encouraged on
well-mixed diet
10/10/14
Blood
4.50-5.50 (106/uL)
Normal
No treatment given
10/10/14
Blood
White
Cell 7.32(103/uL)
2.60-8.50 (103/uL)
No treatment given
blood
count
10/10/14
Abdominal
Exploratory Laporotomy
x-
the intestine
obstruction
the
rayAbdomen
Abdominal x-ray to
bowels.No evidence
of bowel obstruction.
obstruction
of
the bowels
10/10/14
Serum
Sodium
134mmol/L
135-145mmol/L
Normal
No treatment given.
Chlorine
102mmol/L
97-110mmol/L
Normal
No treatment given.
Potassium
2.7mmol/L
3.5-5.5mmol/L
Normal
No treatment given.
Calcium
2.49mmol/L
2.15-2.55mmol/L
Normal
No treatment given.
Electrolyte
10/10/14
Serum
Electrolyte
10/10/14
Serum
Electrolyte
10/10/14
Serum
Electrolyte
CLINICAL MANIFESTATION
CLINICAL MANIFESTATION
OUTLINED IN LITERATURE
1. Colicky abdominal pain.
EXHIBITED BY CLIENT
1. Client complained of colicky abdominal pain.
6. Constipation.
8. Pallor.
9. Dehydration.
With reference to the literature review on the treatment for Intestinal Obstruction, the following
treatment was given to the patient;
SURGICAL TREATMENT
(1) Exploratory Laparotomy, bowel resection and end to end anastomosis done.
(2) Nasogastric tube was passed to reduce abdominal distension and prevent aspiration.
TABLE THREE:
PHARMACOLOGY OF DRUGS ADMINISTERED TO MRS G.A.
DATE
10/10/14
DRUG
Intravenou
DOSAGE AND
DOSAGE AND
ROUTE OF
ROUTE OF
ADMINISTRATION
ADMINISTRATION
PER LITERATURE
Adult Dose: 5-10mg
TO CLIENT
10mg daily 2 days
Tranquilizer,
Relaxes
intravenously.
antianxiety, and
skeletal
relieved.
hypoactivity.
4hours p.r.n
skeletal muscle
muscles and
relaxant.
relieves
s Diazepam repeated in 3 to
CLASSIFICATION
10/10/14
ACTUAL
SIDE EFFECTS/
EFFECTS
ACTION
REMEDIES
OBSERVED
per kg in 8hours
10/10/14
DESIRED
muscle
Dextrose
Route: Intravenous
Dosage depends on
spasms.
Provides
Client was
Confusion, fluid
saline
intravenously
replacement.
supplementar
hydrated and
overload, oedema,
requirement
y calories and
energy restored.
(Intravenously)
fluids.
Depends on the rate of 1.5 litres for 48 hours Fluid and electrolyte
Restores
Ringers
observed.
Client regained
Fluid overload,
lactate
dehydration
intravenously
replacement
Route: Intravenous
normal fluid
normal fluid
hypertension,
and
and electrolyte
hypocalcaemia,
electrolyte
balance
hypocalcaemia.
balance
10/10/14
Normal
Highly individualised
Restores
Client sodium
Oedema, potassium,
saline
(Intravenously)
intravenously.
replacement
normal
and chloride
Hypocalcaemia.
sodium and
level were
chloride level
normal as she
did not exhibit
signs of fluid
retention
11/10/14
Intravenou
100mg stat
s Pethedine
100mg every3 to
intramuscularly
Narcotic analgesic.
Relieves pain
Client was
Nausea, vomiting,
4hours, p.r.n.
observed
kg
11/10/14
Intravenou
Route: Intramuscular
Adult: 400mg bd
400mg bd 5
intravenously
Antibiotic
Kill
No infection
Gastrointestinal
susceptible
was noticed
disturbance, nausea,
bacteria to
vomiting, diarrhoea,
cin
prevent
infection
depression.
Route: Intravenous
Intravenou
Adult: 400mg-500mg
Antiprotozoa
To treat
No infection
Vertigo, abdominal
tds7days
intravenously
Amoebicide
infection.
noticed.
cramps.
Metronida-
zole
7days.
Route: Intravenous
11/10/14
Intravenou
sKetamine
225mg Intravenously.
Anaesthetic agent.
Acts on the
Client slept
per kg adjusted
central
throughout the
tremors, drowsiness,
according to response
nervous
surgical
restlessness,
system to
procedure.
hypotension, dystocia.
per kg
produce
Route: Intravenous
tranquilation
Dries
Decrease
Drowsiness, blurred
and sleep.
11/10/14
11/10/14
Intravenou
s Atropine
before anaesthesia
secretions,
secretions were
60mins before
intravenously
decreases
observed during
mouth, urinary
anaesthesia
sweating and
the surgery.
hesitancy.
salivation
Intravenou
Route: Intravenous
Adult Dose: 1-2mg to
80mg intravenously
a maximum of 150mg
during surgical
Suxameth-
Antisecretory agent.
Anaesthetic agent
Relaxes
Clients skeletal
Bradycardia, cardiac
skeletal
muscles were
arrhythmia, cardiac
muscles.
relaxed
arrest, respiratory
ionum
11/10/14
per kg
throughout the
depression, apnoea.
Route: Intravenous
surgery.
Intravenou
2.5mg intravenously
Cholinergic
To relax
Clients
Dizziness, headache,
skeletal
muscles
Neostigmi-
0.08mg per kg
cholinesterase
muscles.
relaxed
ng
Route: Intravenous
12/10/14
Tablet
500mg bd5days
orally
Antibiotic
Kill
No infection
Gastrointestinal
susceptible
was noticed
disturbance,
14days.
bacteria to
nausea, vomiting,
prevent
30mg/kg in two
infection
and depression.
13/10/14
Tablet
Diclofenac
Antipyretic,
Relieves
Client was
Anxiety, dizziness,
150mg bd
sedative,
inflammation,
relieved of and
depression, oedema,
NSAID
pain and
her temperature
drowsiness,
fever.
reduced.
insomnia,
bd
Route: Oral, rectal
50mg bd 5 orally.
irritability,
migraine, headache,
hypertension, taste
disorder.
None was observed.
Client coped well during the pre-operational preparation and also verbalized her fears.
Client was alert and oriented to time, place and person and could communicate her pain.
Client was ready to know more about her condition.
Client was insured with the national health insurance scheme.
Client and family fully participated in the planning of her care and client.
Client was very friendly and co-operative and had a cordial relationship with other clients
on the ward as well as the staff.
HEALTH PROBLEMS
A health problem is any stress, be it physical, mental or social in a patient that prevents the client
from meeting a certain health standard. Hence client may need some professional services. They
were identified as pre-operative and post-operative problems.
The following health problems were identified upon assessing Mrs. G.A.;
(2)
Client was anxious of impending surgery (patient had emotional support from family
members).
(3)
Client had no knowledge of the disease condition and its management (Intestinal
obstruction). (client was ready to learn more about condition)
(4)
Client complained of abdominal pains. (client tolerated analgesics and cooperated with
diversion therapy)
Client was likely to have difficulty in breathing due to the effects of anaesthesia (client
was ready to learn pre-operative teaching such as deep breathing exercise and coughing).
(2)
Client could not perform her personal hygiene ( client understood the importance of good
Client was prone to wound infection (client cooperated with wound dressing procedures
(5)
(2)
(3)
(3)
Self-care deficit (bathing and grooming) related to general weakness after surgery.
(4)
(5)
CHAPTER THREE
PLANNING FOR CLIENT AND FAMILY CARE
Nursing care plan is a systematic process designed to enhance delivery of nursing care on
individualized basis. It forms the third step in the nursing process, which is an approach to
clients care and serves as communication link between client and the health team. This
encourages the nurse to use her initiatives in nursing the patient. The nursing care plan is a
written guide that directs the efforts of the nursing team to meet health goals. It ensures that, the
nursing team works efficiently to deliver holistic, goal-oriented and individualized care to client.
PRE OPERATIVE NURSING OBJECTIVES
(1) Client will be relieved of anxiety within 30 minutes.
(2) Client will have normal fluid volume during the period of Nil per os.
(3) Client will have adequate knowledge on the disease condition (Intestinal Obstruction)
within 45 minutes.
(4) Client will be relieved of abdominal pains within 1 hour.
(4) Client wound will be free from infections and heal well within 9 days.
(5) Client will be free from urinary tract infections within the period of catheterisation.
TABLE FOUR:
NURSING CARE PLAN FOR MRS GIFTY OKYERE
DATE
NURSING
NURSING
NURSING ORDERS
AND
DIAGNOSIS
OBJECTIVE/
AND
TIME
OUTCOME
TIME
10/10/14
Fluid volume
CRITERIA
Client will be
at
deficit
8:00am
NURSING INTERVENTION
DATE
12/10/1
relieved of
at
(dehydration)
vomiting and
vomiting.
8:00pm
related to
will have
excessive
normal fluid
vomiting.
volume within
and severity of
48 hours as
evidenced by;
immediately.
Patient showing
no signs of
dehydration such
as sunken eyes
turgor.
4). Administer
prescribed intravenous
strict intake and output intake and output chart was monitored
chart.
5).
and maintained.
Document
procedure.
nurses notes
DATE
NURSING
OBJECTIVE\
NURSING
AND
DIAGNOSIS
OUTCOME
ORDERS
TIME
10\10\14
Alteration in
CRITERIA
Client will be
at
body comfort
relieved of pain
9:20am
(abdominal
within 1 hours as
pain) related
evidenced by;
to Intestinal
Client feeling
2).Perform pain
Obstruction.
comfortable in bed
assessment.
and verbalizing
NURSING INTERVENTION
T
1). Client was reassured that, pain 1
absence of pain.
3). Assist client to
assume
comfortable
position.
4). Remove
constricting and or
was removed.
tight clothing.
5). Reduce noise.
6). Provide
dimensional
therapy.
7). Administer
prescribed
analgesics.
8).Document
procedure.
DATE
NURSING
NURSING
NURSING
NURSING
DATE
AND
DIAGNOSIS
OBJECTIVE/
ORDER
INTERVENTION
AND
TIME
OUTCOME
TIME
10/10/14
Anxiety
CRITERIA
Client and will be
1).Reassure
10/10/14
at
related to
relieved of anxiety
client.
at
11:30am.
impending
within 30 minutes
12:00pm.
surgery
as evidenced by;
(Intestinal
a). Client
2).Assess clients
Obstruction)
state of anxiety,
and its
is relieved of
outcome.
anxiety.
b). Nurse observing
3).Explain to her
the theatre
cheerful facial
environment and
expression.
4).Allow client to
express concern.
5).Employ
diversional
therapy
allay fears.
DATE
NURSING
NURSING
NURSING
NURSING
DATE
AND
DIAGNOSIS
OBJECTIVE/
ORDERS
INTERVENTION
AND
TIME
OUTCOME
TIME
CRITERIA
10/10/14
Knowledge
Client and
10/10/14 G
at
deficit related
relatives will
and family.
at
3:00pm.
to disease
have knowledge
educate them.
3:45pm.
condition
on intestinal
(intestinal
obstruction
2).Ensure quiet
obstruction).
within 45
environment.
minutes as
and staff.
evidenced by;
a). Client and
3).Provide a
relatives
verbalising that
relax them.
they understand
4).Assess their
clients
previous
condition.
knowledge on the
condition.
b). Client
ability to give
correct
the disease
feedback on the
disease
management.
condition
(Intestinal
obstruction).
family to ask
questions.
understanding with
feedbacks.
and family in
planning of care.
DATE
NURSING
NURSING
NURSING
AND
DIAGNOSIS
OBJECTIVE/
ORDERS
TIME
OUTCOME
11/10/14
Potential for
CRITERIA
Client will have a
at
dyspnoea
6:20am
NURSING INTERVENTION
DATE
AND
TIME
1).Reassure client
11/10/14
patent airway
at
related to
within 45 minutes
7:05am
ineffective
as evidenced by
and anxieties.
airway
nurse observing
clearance due
to anaesthesia.
normal respiration
2).Set a
resuscitation tray.
airway.
in the appropriate
position which is
not contra
indicated.
frequently.
5).Observe client
symptoms for
respiratory
distress such as
dyspnoea and
cyanosis.
6).Monitor vital
signs every 15
minutes, 30
minutes, 1 hour,
as clients
condition.
condition
improve.
DATE
NURSING
OBJECTIVE/
NURSING
AND
DIAGNOSIS
OUTCOME
ORDERS
TIME
12/10/14
Alteration in
CRITERIA
Client will be
at
9:00am
NURSING INTERVENTION
TIME
AND
DATE
13/10/14
at
related to
within 24 hours
9:00am
surgical
as evidenced by:
incision
a). Client
verbalizing that
assume a
she is relieved of
pain.
pain.
b). Nurse
observes client
3).Provide
having a cheerful
facial expression
pain.
and looking
4).Teach client to
relaxed in bed.
laughing.
DATE
NURSING
OBJECTIVE/
AND
DIAGNOSIS
OUTCOME
TIME
13/10/14
7).Document the
procedure.
NURSING
nurses notes.
NURSING INTERVENTION
TIME
ORDERS
AND
Self care
CRITERIA
Client will be able to
1).Reassure
DATE
16/10/14
at
deficit (total)
client.
6:25am
related to
needs without
incisional
assistance or with
wound.
minimum assistance
within 72 hours as
evidence by;
a). Observing client
taking her bath,
grooming and caring
2).Assist client to
6:25am.
3).Treat Pressure
without assistance.
areas.
4).Give oral
toileting twice
daily.
5). Encourage
early ambulation.
6).Change soiled
linen as often as
possible and
NURSING
creases.
OBJECTIVE\
AND TIME
DIAGNOSIS
OUTCOME
NURSING
NURSING
DATE
ORDERS
INTERVENTIO
AND
13\10\14
Potential for
CRITERIA
Client will not
1).Reassure
N
1).Client was reassured that strict
at
post
develop post
patient.
8:00am
operative
operative wound
wound
infection throughout
wound infection.
infection
related to
period
2) .Change soiled
surgical
(9 days) as
dressings
incision.
evidenced by;
frequently and
a).The clients
aseptically.
wound looking
from exudates.
3).Educate client
to avoid touching
wound healing by
4).Administer
prescribed
antibiotics.
first intention.
infection.
5).Encourage
adequate
nutrition.
6). Document
procedure.
nurses notes.
NURSING INTERVENTION
DATE
NURSING
OBJECTIVE\
NURSING
AND TIME
DIAGNOSIS
OUTCOME
ORDERS
14\10\14
CRITERIA
High Risk for Client will be free 1). Reassure
at
infection
from
catheterization is temporal.
8:00am
(urinary tract
infection)
catheterization
related to
evidenced by;
catheter daily
catheter
Nurse observing no
with antiseptic
insitu
signs of discharges
lotion.
infection client.
absence of dysuria.
drainage bag in a
container.
bag in a right
drainage.
5). Monitor
temperature