ST.

PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING
SY 2021-2022 SECOND SEMESTER

NURSING CARE PLANS

Patient’s Name (Initials): E.N. Admitting Diagnosis/Medical Diagnosis/CC: Sickle-Cell Anemia

Age: 14 years old Sex: Male Physician (Initials): Dr. J. G.
Room No: 002 Diet: NPO
Subjective Objective Nursing Scientific Planning Interventions Rationale Expected Outcome
Diagnosis Analysis
“Maam - Open wound Risk for The patient is Short term: Independent: Independent: After nursing
makabatyag w/colostomy infection taking care of That after 2 - Vital Signs - To check if interventions
ug bag related to a cow, hours of were monitored there are the patient
gipanugnawan - Surgical inadequate gathering fire nursing every 3 hrs. improvements will:
bisag incision in primary woods and doing interventions and assess in the patient - Demonstrate
palngon na the midline defenses some of the , the level of Vital Signs the
ang aircon” of abdomen household patient: discomfort of and scale of appropriate
as - Use of Definition: chores with the - Will be pain each time discomfort care of
verbalized accessory Vulnerable to help of his son able to after giving infection
by the muscles invasion and and demonst information. prone sites
patient multiplication unexpectedly he rate such as
- Pale
of pathogenic had noticed a appropr colostomy
Laboratory
organism, lack of energy iate - Wash hands - Reduces the care
Results:
which may three days care of before or after risk of cross - Remained
compromised prior to infecti each care contamination free from
WBC- 13.30
health. admission due on- activity; even because gloves symptoms of
cells/mm3
to abdominal prone gloves are may have infection
Neutrophil-
pain. sites used. noticeable - Achieved
93.00/mm3
Perforated such as defects, get healing in
Lymphocyte-
References: Cecum is a colosto torn or surgical
3.70/mm3
Doenges,M., blowout of the my care damaged during incisions
MPV- 7.70/fl
Moorhouse, M., wall of the - Will use. and free
and Murr,A cecum caused by remain from
(2019). Nurses overdistention free infection
Pocket Guide: which results from - Inspect wounds - May provide
Diagnosis from remote symptom or sites of clue to portal Evaluation
Prioritize obstruction of s of invasive entry, type of Goals are MET
interventions the distal infecti
 ST. PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
SY 2021-2022 SECOND SEMESTER

and rationale. colon. Patient on procedure, primary for patient:

15th Ed. with perforated paying infecting
Philodelpha cecum will Long Term: particular organisms, as - Was able to
probably have a attention to well as early show
manifestation That after 1 parenteral identification correctly
of abdominal month of lines secondary the
pain, chills, nursing infection appropriate
fever, bleeding intervention care of
from rectum the patient: - Teach the - Knowledge of infection
because - Achieve patient ways to reduce prone sites
Bacteria will timely concerning or eliminate such as
be able to healing colostomy care germs reduces colostomy
enter, and the likelihood care
potentially free of - Is already
leading to a from transmission free from
condition further symptoms of
called infecti infection
peritonitis and on - Advise the - Restricting - Wounds are
Peritonitis client to limit visitation healed and
is inflammation visitors reduces no further
of the transmission infection
peritoneum, the of pathogens noted.
thin layer of
tissue that - Monitor the - These are the
lines the redness, classic signs
abdomen. swelling, pain, of infection.
Without purulent Any Suspicious
treatment, discharge from drainage
peritonitis can incisions, exit should be
cause blood sites of tubes, cultured.
poisoning, and drains
or sepsis that
will possibly
- Observe for - Chills often
cause fever.
chills and precede
Our patient
profuse temperature
undergo
diaphoresis spikes in
exploratory
 ST. PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
SY 2021-2022 SECOND SEMESTER

laparotomy it presence of
is a general generalized
surgical infection
operation where Dependent: Dependent:
the abdomen is - Administer - To prevent
opened and the antibiotics as further spread
abdominal organs prescribed by of infection
are examined for
the physician.
injury or
disease and
Collaborative:
right
hemicolectomy it - Obtain - Identification
involves the Specimens of of portal
removing of the urine, blood, entry and
right side of sputum, wound organism
the colon and as indicated causing the
attaching the for gram stain, septicemia is
small intestine and sensitivity crucial in
to the effective
remaining treatment
portion of the
colon. These
procedures were
done to our
patient in
order to find
the cause of
problems (such
as belly pain
or bleeding)
that testing
could not
diagnose or if
your colon has
been affected
by a condition,
specifically,
 ST. PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
SY 2021-2022 SECOND SEMESTER

trauma or
injury to your
abdominal area
or has become
cancerous.
According to
Sepsis
Alliance, A
perforated
cecum occurs
when hole
develops in
your bowel
wall, part of
your
gastrointestina
l (GI) tract.
The GI tract
runs from your
throat to your
rectum. Food
travels down
your esophagus,
into your
stomach, where
it empties into
your small
intestine, and
then into your
large
intestine, or
bowel. If the
perforation
occurs in your
bowel, it may
be called a
perforated
 ST. PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
SY 2021-2022 SECOND SEMESTER

cecum.
If your GI
tract is
perforated, the
contents may
spill into your
abdomen and
cause
peritonitis, an
infection. Such
an infection
can lead to
sepsis.
Sometimes
incorrectly
called blood
poisoning,
sepsis is the
body’s often
deadly response
to infection.
Like strokes or
heart attacks,
sepsis is a
medical
emergency that
requires rapid
diagnosis and
treatment.
Sepsis and
septic shock
can result from
an infection
anywhere in the
body, such
as pneumonia, i
nfluenza,
 ST. PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
SY 2021-2022 SECOND SEMESTER

or urinary
tract
infections.

References:

Perforated
bowel.
Sepsis
Alliance.
(2022, May
3).
Retrieved
May 16,
2022, from
https://www
.sepsis.org
/sepsisand/
perforated-
bowel/