NURSING CARE PLAN

Patient’s Initials: J.C. Chief Complaint: Swelling of the incision SN: Domingo,

Age & Gender: 20 years old Admitting Diagnosis: Swelling of the incision site,

associated with pain and redness.

Birth date: October 15, 2000 Date of Confinement: August 12, 2021

Address: Mayombo Dist., Dagupan City Level/Block/Group: 3BSN5 Clinical Instructor: Sir Jesus Rabe

ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Due to the presence of
Subjective: pain and swelling at the Short-Term Goals:  Maintain strict asepsis  Strict asepsis will After 4 hours of nursing
Pain at the incision incision site, patient is After 4 hours of nursing for wound care. decrease chances of intervention, goal partially
site, profuse most likely at risk for intervention: transmitting/spreading met.
sweating. "Masakit post-op. infection.  Ensure that articles to pathogens to or
yong part na  The patient will show be used by the patient  The patient verbalized
between the patient.
tinahian sa akin." NURSING DIAGNOSIS: less grimacing "I am feeling better
are properly  To eliminate harmful
as verbalized by Risk for infection related because of pain now."
the patient. to pain and swelling of disinfected and microorganisms and
caused by the sterilized before use. further infection.  The patient rate a pain
Objective: the incision site.
infection.  Teach patient to take scale of 5/10.
Facial Grimacing
Redness and  The patient will give anti-infective drugs as  Redness disappeared,
Swelling at the a 4/10 pain scale prescribed.  Not completing the swelling is lessened.
incision site. rating. (Antibiotics). prescribed antibiotic  The patient shows
BP: 110/70  Redness and swelling can lead to reactivation normal Vital Signs.
PR: 81bpm at the incision  Encourage sleep and of symptoms.
RR: 17 breaths per (appendectomy) will rest to the patient.
minute be lessened.
Temp: 38.1°C  This is to modulate the
 The body immune responses of
O2 Sat: 98%
temperature of the  Demonstrate and allow the patient.
patient will go down return demonstrations
of procedures like
 to its normal state. dressing changes.
 Showing
 Give pain medications demonstrations to the
Long-Term Goals as prescribed to the patient and to the
 The patient will patient, to alleviate family members will
remain free from pain in the incision site. keep cooperation
infection, as among them with
evidenced by normal specific precautions.
vital signs.
 The patient will show  To reduce pain felt by
absence of signs and the patient.
symptoms of
occuring infection.