Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

College of Nursing
Website: [Link] Mail: unpnursingvc@[Link]
CP# 09177148749, 09175785986
Nursing Care Plan
Name of the Patient: MG
Age: 27 yrs. Old Sex: Female

NURSING PLANNING
SCIENTIFIC
ASSESSMENT DIAGNOSI NURSING INTERVENTION RATIONALE EVALUATION
REASON
S
Short-Term Goal: INDEPENDENT:
Subjective: Risk for Wounds involving Within the shift,  Fever may indicate Goal met:
“Kaninang umaga infection injury to soft tissue patient will be  Assess signs and symptoms infection.
lang ako related to can vary from minor able to identify of infection especially Patient was free
naoperahan”; as post-surgical tears to severe ways to reduce temperature. from any signs and
verbalized by the incision crushing injuries. risk for infection. symptoms of
patient. The decision to  Emphasize the importance  It serves as a first line of infections as
suture a wound Long-Term Goal : of handwashing technique. defense against manifested by
depends on the At the end of infection. absence of fever,
Objective: nature of the wound hospitalization,  Maintain aseptic technique redness and
the time since the patient will not when changing swelling of surgical
Vital signs taken as injury was sustained manifest any signs dressing/caring wound.  Regular wound dressing incision site.
follows: the degree of and symptoms of promotes fast healing
contamination. infection.  Keep area around wound and drying of wounds.
T- 36.5 °C clean and dry.
RR- 18 cpm Reference:  Wet area can be lodge
PR- 85 bpm Brunner &  Emphasized necessity of area of bacteria
BP- 120/80 Suddarth’s Textbook taking antibiotics as
mmHg of Medical-Surgical ordered.  Premature
Nursing 11th edition discontinuation of
 Weak in by Smeltzer, Bare, DEPENDENT: treatment when client
appearance Hinkle, Cheever  Administer antibiotics begins to feel well may
 Clean and as ordered by the result in return of
intact physician. infection.
abdominal
dressing
 NURSING SCIENTIFIC PLANNING NURSING EVALUATIO
ASSESSMENT RATIONALE
DIAGNOSIS REASON INTERVENTION N
Subjective: Acute pain related The client is After 2 hours of Independent:
“Masakit yung tahi ko to post-op surgical experiencing pain nursing interventions, Goal met.
talaga at nahihirapan incision as due to the incision the patient will be able Assess vital signs, noting Changes in these vital signs
akong gumalaw”, as evidenced by: done to her after to: tachycardia, hypertensio often indicate acute pain After 2 hours of
verbalized by the the CS operation.  report n, and increased and discomfort. Note: nursing
patient.  Pain scale Pain is a typical comfort and respiration, even if Some patients may have a interventions,
of 8/10 sensory experience relaxation patient denies pain. slightly lowered BP, which the patient was
Objective:  Facial that may be  rate pain returns to normal range able to:
grimace described as the scale from after pain relief is achieved.  report
Vital signs taken as  Guarding unpleasant 8/10 to 3/10 comfor
follows: behavior awareness of a  (-) facial Assess causes of possible Discomfort can be caused t and
 Patient noxious stimulus or grimace discomfort other than or aggravated by presence relaxat
T- 36.5 °C reports of bodily harm.  (-) guarding operative procedure. of non-patent indwelling ion
RR- 24 cpm pain Individuals behavior catheters, NG tube,  rate
PR- 85 bpm  Narrowed experience pain by  (-) narrowed parenteral lines pain
BP- 120/80 focus various daily hurts focus (bladder pain, gastric fluid scale
mmHg  irritability and aches, and  (-) irritability and gas accumulation, and from
occasionally infiltration of IV fluids or 8/10 to
 Pain scale: through more medications). 3/10
8/10 serious injuries or  (-)
 Facial grimace illnesses. May relieve pain and facial
and guarding Reposition as indicated: enhance circulation. Semi- grimac
 behavior ([Link] semi-Fowler’s; lateral Fowler’s position relieves e
 Patient .org Sims’. abdominal muscle tension  (-)
reports of pain /wiki/pain) and arthritic back muscle guardi
 Narrowed tension, whereas lateral ng
focus Sims’ will relieve dorsal behavi
 irritability pressures. or
 (-)
Relieves muscle and narrow
emotional tension; ed
Encourage use of enhances sense of control focus
relaxation techniques: and may improve coping  ;(-)
deep-breathing exercises, abilities. irritabi
guided imagery, lity
visualization, music. Approach to postoperative
pain management is based
Note patient’s age, on multiple variable
weight, coexisting factors.
medical or psychological
conditions, idiosyncratic
sensitivity to analgesics,
and intraoperative course.

Review intraoperative or
recovery room record for Presence of narcotics and
type of anesthesia and droperidol in system
medications previously potentiates narcotic
administered. analgesia, whereas patients
anesthetized with
Fluothane and Ethrane have
no residual analgesic
effects. In addition,
intraoperative local/
regional blocks have
varying duration, e.g., 1–2
hr for regionals or up to 2–
6 hr for locals.
Evaluate pain regularly
(every 2 hrs noting Provides information about
characteristics, location, need for or effectiveness of
and intensity (0–10 scale). interventions. Note: It may
Emphasize patient’s not always be possible to
responsibility for eliminate pain; however,
reporting pain/ relief of analgesics should reduce
pain completely. pain to a tolerable level. A
frontal and/or occipital
 headache may develop 24–
72 hr following spinal
anesthesia, necessitating
recumbent position,
increased fluid intake, and
notification of the
anesthesiologist.

Dependent:

Administer analgesics Helps in alleviating the