NURSING CARE PLAN

ASSESSEMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Swelling of the Risk for infection After 1 hour of  Assess for presence  To determine GOAL MET:
surgical site related to alteration in effective nursing of host-specific factors that After 1 hour of
skin integrity intervention, the factors that affect can increase effective nursing
patient will be able to immunity (e.g susceptibility intervention, the
identify interventions lifestyle, nutritional to infections patient was be able to
to prevent or reduce status, trauma, and identify interventions
risk of infection environmental to prevent or reduce
exposure) risk of infection as
 Observe at-risk  This could be evidenced by
client for changes signs of  Demonstrate
in skin color and developing ways on how
warmth at localized to prevent
insertion sites of infection infection
invasive lines,  Verbalize
sutures, surgical understanding
incisions and of causative or
wounds risk factors
 Practice and  To minimize
emphasize contamination
constant and of hands
proper hand
hygiene between
nurse and patient.
 Clean incisions and  To reduce the
insertion sites per potential for
facility protocol bloodstream
 with appropriate infections and
antimicrobial to prevent the
topical or solution. growth of
bacteria
 Instruct the  To promote
client/SO in cleanliness in
techniques to the surgical
protect the site and
integrity of the skin prevent the
and prevent spread patient from
of infections acquiring
infection

 Provide
 To increase
information and
awareness of
involve the client in
and
appropriate
prevention of
community
communicable
education
diseases
programs
 ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Impaired comfort After 1 hour of effective  Discuss concerns  This helps to GOAL MET:
“Haanak related to surgical nursing intervention with the client and determine the After 1 hour of
komportable nga procedure as the patient will be able active listen to clients specific
effective nursing
manifested by to verbalize of comfort identify underlying needs and
garaw nga garaw intervention the
issues that could ability to
kasi atuy kaop subjective and or contentment patient was be
impact the client change own
opera kanyak” as objective cues able to verbalize
ability to control situation.
verbalized by the of comfort or
own well – being.
patient   Determine the  An aspect that contentment as
client environment can be evidenced by
Comfort scale –
both aspects manipulated  Comfort
4/10
privacy and to enhance scale-10/10
Objective: provides natural comfort.
 Irritability lightning with
readily accessible
view to outdoors.
 Validate client  This consider
understanding of client family
client’s situation needs in this
and ongoing area and
methods of shows
managing appreciation
condition as for their
appropriate and or desires.
desired by client.

 Review knowledge  This brings

these to
 base and note client’s
coping skills that awareness and
have been used promotes use
previously to in the current
change behavior situation.
well - being.
 To provide
 Provide age– non-
appropriate pharmacologic
comfort measures. al pain
management
 Encourage/plan
care to allow  To prevent
individually fatigue.
adequate rest
periods.  The nurse
could be most
 Interact with the important
client in a intervention
therapeutic for meeting
manner. client’s. For
example,
assessing the
client that
nausea can be
treated
successfully
with both
pharmacologic
 al and non-
pharmacologic
al methods
may be more
effective than
simply
administering
an antiemetic
without
reassurance
and a
comforting
presence.

 Establish realistic  This enhances

activity goals with commitment
the client. to promoting
optimal
outcome.

ASSESSEMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Deficient knowledge After 1 hour of GOAL MET:
”Haan ku unay ammu related to disease as effective nursing  Identify patients  To determine After 1 hour of
sakit ku ken operasyon manifested by inability intervention the level of level of effective nursing
nga inubra da kinyak to understand patient will be able to understanding. teaching intervention, the
ate” information . verbalize  Provide positive  This could patient was able to
understanding reinforcement . encourage verbalize
condition, disease continuation understanding
Objective:
process and of efforts. condition, disease
 treatment. process and treatment
 Discuss the clients  To make the as evidenced by
perception of clients feels 
need.Relate the competent
information to the and respected.
clients personal
desire,needs ,value
and beliefs.

 Provide
 This may assist
information about
with further
additional learning
learning and
resources.
promote
learning in her
own pace.

 Identify
 Enhance
information that
possibility that
needs to be
information
remembered.
will be heard
and
understood.