POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC.

MacArthur Highway, Brgy. Kiagot, Digos City, Davao del Sur, Philippines 8002

NURSING CARE PLAN

Name of Patient:         MR B                                                         Attending Physician:          Dr Reyes                                    
Age:    54          Sex:     M        Civil Status:           Married                       Diagnosis:                                                                
Occupation:                           Religion:         Roman Catholic                          
Address:                                                                        Chief Complaint:                                                                                      
Ward:        surgery              Room No:     107         Bed No:                  Date of Admission:                                                                          

Date/ Cues Needs Nursing Scientific  Basis Goals/Objectives Nursing Rationale Evaluation
Time Diagnosis /Criteria Interventions
1/23/2 -Improper P Risk for infection -An invasion -at the end of a -change the -changing the -upon the
3 neck H as evidenced by or growth 30mins span of dressing and make dressing reduces 30 mins
dressing surgery sutures of germs nursing sure not to expose the risk for germ span of
Y at the interventions:
noted in the body the wound growth and nursing
S right or at the site -advise the avoiding exposing intervention
-pallor skin I sternocleidomastoid of injury Bacterial growth watcher to the wounds can goal have
noted O (neck) may cause will be reduced perform TSB help reduce the been met.
L infection and from the body to -advise the microorganism
avoid the risk for watcher to change entering the
-sweaty and O can be a
infection
soiled stimuli for ,dry and clean wound
G clothing
clothing another
I -change and -TSB is an
noted complication
C such as fever, provide new clean essential
-with dirty bed linen procedure to
swelling on the
long finger -advise to cut the reduce the growth
wound site,
nails noted finger nails short of microorganism
skin decay or -advise the in the body and
worse death watcher to wash promotes
-body mallei
noted if not prevented hands before and comfortability
accordingly. after touching the
-soiled bed patient -changing clothes
linen noted can help promote
relaxation and
well being

-providing new
linen can reduce
bacterial
accumulation over
time and
promotes comfort

-cutting the nails

short helps the
reduction of
bacterial contact
and the spread of
microorganism
into the body

-washing the
hands before and
after can help
avoid the spread
of microorganism
to the patient and
to protect
oneselves.
Student Name:                                                           Year & Sec.:                        Group No.:                  Rating:                  
Reference:                                                                                                                                                        
Criteria:  Promptness (5%)        Assessment (15%)       Objectives of care (10%)  Evaluation (10%)
         Format/Neatness (15%)  Nursing Diagnosis (15%)  Nursing Action (30%)  
Clinical Instructor: