NURSING CARE PLAN 2

Patient’s Name: D.V Chief Complaint: Itchiness, skin rashes, swelling and tenderness of left hand
Age/Sex: 43 years old/ Male Admitting Diagnosis: Collar button abscess 5th webspace left hand
Room/Ward: Male Surgical Ward Attending Physician: Dr. Tan

General objective: To facilitate the maintenance of fluid and electrolyte balance.

CUES NURSING EXPECTED NURSING RATIONALE EVALUATION
DIAGNOSIS OUTCOMES INTERVENTION
Subjective: Independent:
Excess fluid volume Within 3 days of After 3 days of rendering
“Nagapamanug ang related to rendering nursing  Assess patient’s vital  Alteration in vital signs is nursing intervention, the
inflammation on intervention, the patient signs. evident in the presence of goal was partially met. The
akon wala nga kamot.
will be able to: pain. patient will be able to
Nagakatol pud sya kag surgical site as
demonstrate behaviors to
naga rashes ko sang evidenced by monitor fluid status and
pagkadto ko di ospital.” swelling of left - Demonstrate behaviors  Assess the patient’s  To obtain baseline data and to reduce recurrence of fluid
“Pagkatapos opera, hand. to monitor fluid status condition. plan for the appropriate care. excess, follow prescribed
nagasakit man ang and reduce recurrence of pharmacological regimen,
fluid excess. verbalize understanding of
tinahi-an sang akon  Inspect skin for  To indicate areas of poor individual dietary and fluid
wala nga kamot.” As changes in color, circulation or breakdown that restrictions, and absence of
verbalized by the - Follow prescribed turgor, vascularity, may lead to infection. swelling and tenderness of
patient. pharmacological and note redness. left hand, facial grimace,
regimen. guarding behavior, and
 Monitor fluid intake  To detect presence of irritability.
Objective:
- Verbalize and hydration of skin dehydration or overhydration
understanding of and mucus that affect circulation and
- Swelling and tissue integrity at the cellular
individual dietary and membranes.
tenderness of left hand fluid restrictions. level.

- Surgical incision site Dependent:

on left hand - Absence of swelling
and tenderness of left  Administer anti-  To relieve pain and swelling
hand, facial grimace, inflammatory drugs during acute attacks.
- Guarding behavior
guarding behavior, and as ordered by the
irritability. physician.
-Facial grimace
  Monitor the effects of  To prevent any adverse
- Skin rashes drugs given. effect.

- Itchiness
Collaborative:
- Irritability
 Assist with medical  This includes drainage,
- Limited range of procedures. wound dressing, etc.
motion

- Pain scale of 7/10  Identify specific  To have a timely and

signs/symptoms in appropriate assessment of the
pain requiring follow- patient and to see further
up check-up. signs/symptoms.

References F.A Davis Nurse’s Pocket Guide Fourteenth Edition