DIVINE WORD COLLEGE OF BANGUED

Bangued, Abra

Department of Nursing
Bachelor of Science in Nursing
Name: _____________________________ Score:__________ Rating:__________ Date:_________
Course & Year:__________ Instructor’s Signature:____________

NURSING CARE PLAN

Assessment
Subjective Data:
“medyo nasakit toy dait ko ma’am”
Objective Data:
- (+) surgical incision
- no redness or swelling on incision site
- wound dressing dry and intact with no purulent discharge
- G4P4
- vital signs as follows:
 BP: 120/80 mmHg
 T: 36.4°
 PR: 90 bpm
 RR: 19 CPM
 O2 Saturation: 98%
Nursing Diagnosis
Impaired skin integrity related to surgical incision
Planning
After 1 hour of nursing interventions, client will verbalize a plan of care to maintain uncompromised skin integrity.
 Nursing Interventions Rationale
 Monitored and recorded vital signs  Autonomic responses include, changes in blood pressure,
pulse, respiration, associated with pain relief.
 Regulated IVF infusion  Regulation ensures the correct amount of fluid drips from
a bag down the IV into the vein at the correct rate.
Complications can result from receiving too much too
quickly, or not enough too slowly.
 Assessed wound and dressing and noted for any signs  To detect any abnormalities as soon as possible to prevent
of infection further complications
 Encouraged patient to verbalize pain or discomfort  Feedback and verbalization of pain can assist the care
team in modifying and improving plan of care
 Encouraged patient to rest  Decrease muscle tension, increase relaxation, and
increased sense of control and coping abilities.
 Supervised and assisted in oral intake of medicines as  To ensure timely healing and effective treatment.
ordered
 Emphasized the importance of breastfeeding to both  Breastfeeding releases hormones that can help the uterus
mother and newborn to contract and return to its pre-pregnancy size, which can
aid in post-operative healing and recovery.
 Educated on the risk factors for infection as well as  Being aware of these symptoms promotes early
signs and symptoms intervention.
 Instructed on wound care  Knowing the importance of clean dressing changes and
the importance of each step reduces the risk of infection
and complications.
 Promoted actions that help with timely wound healing  These include ambulation, intake of protein-rich food as
well as intake of vitamin-rich food
Evaluation
After 1 hour of nursing interventions, client will verbalize a plan of care to maintain uncompromised skin integrity.
 Goal met
 DIVINE WORD COLLEGE OF BANGUED
Bangued, Abra

Department of Nursing
Bachelor of Science in Nursing
Name: _____________________________ Score:__________ Rating:__________ Date:_________
Course & Year:__________ Instructor’s Signature:____________

NURSING CARE PLAN

Assessment
Objective Data:
Temperature – 35.1 °C
BP – 100/70 mmHg
PR – 72 bpm
RR – 20 BPM
SpO2 – 98 %
Nursing Diagnosis
Risk for infection related to invasive procedure
Planning
After 6 hours of rendering nursing interventions, the client will be free of signs of infection,
inflammation, purulent drainage, erythema, and fever.
Nursing Interventions Rationale
 Assessed level of pain and  Serves as a baseline for rendering care
monitored VS  Early detection of signs and symptoms of infection
 Monitored and assessed for signs of will lead to rendering immediate interventions. If left
infection. untreated, such infection can lead to toxic shock
syndrome, septicemia, kidney failure, and death.
 Educated client on what signs to  Make certain that the client knows the danger signs of
look out for and instructed to report infection, such as fever, abdominal pain or
symptoms indicating complications tenderness, and a foul vaginal discharge.
 Promoted proper perineal hygiene  The organism responsible for infection after
miscarriage is usually Escherichia coli (spread from
the rectum forward into the vagina).
 Maintained sterile technique when  Medical asepsis prevents or limits the introduction of
performing procedures or providing bacteria and reduces the risk of nosocomial infection.
care.
Evaluation
After 6 hours of rendering nursing interventions, the client will be free of signs of infection,
inflammation, purulent drainage, erythema, and fever.
 Goal met