Nursing Care Plan

Assessment
Subjective:
Kumikirot
ang tahi
ko as
verbalized
by the
patient

Nursing
Diagnosis
Acute pain
related to
surgical
Incision

Objective:
Temp: 38 C
BP: 120/80
RR-22
PR- 79

Objectives

Intervention

Rationale

Evaluation

After an
hour of
nursing
interventio
n the
patient will
verbalized
his pain is
relieved or
controlled

Monitor VS
every 15
minutes.

To obtain
baseline
data

Provide
comfort
measure(tou
ch, quiet
environment)

To promote
nonpharmacol
ogical pain
manageme
nt.

After an
hour of
nursing
interventio
n
Pain is
relieved
and
controlled.

Encourage
the patient
to deep
breathing
exercises.

Administered
paracetamol/
analgesic as
prescribed
by the
physician

Assessment
Objective:
Incision
skin at right
lower
quadrant
RR-24
PR-57
Temp.-36.8
BP-120/80
Incision
pain

Nursing
Diagnosis
Risk for
infection
related to
surgical
incision at
RLQ of the
body

Objectives
After
8hours of
nursing
interventio
n the
patient will
be able to
verbalize
and
understand
the

Intervention

Monitor
vs .onset of
fever with
chills, and
pain.

Practice/ins

To reduce
concern of
the
unknown
and
associated
muscle
tension.
To maintain
acceptable
level of
pain

Rationale

Evaluation

Fever and
pain
indicate
inflammato
ry
responses,
which
contribute
to infection

Goal met

Reduces

causative
factor for
the
infection.
Demonstrat
e
techniques
in
minimizing
infection.
Remove all
possible
factors that
may
contribute
to the
infection
process.
Achieve
timely
wound
healing: be
free of
purulent
drainage or
erythema

truct good
hand
washing
and aseptic
wound
care.

Inspect
incision
site.
Note
characterist
ic of
drainage
from wound

Change
wound
dressing as
indicated
using
proper
technique
for
changing/di
sposing
contaminat
ed
materials
Encourage
intake of
fluid and
food that is
rich in
Vitamin C

the risk for

infection or
cross
contaminati
on of
bacteria
Provides
early
detection of
infection
process
and
presence of
discharges
may help to
identify
whether
the skin
has an
infection
To
reduce/corr
ect existing
risk factors

Promotes
healing and
prevents
dehydratio
n

Assessmen
t
Subjective:
Feeling
breathless
Objective:
Alterations
in depth of
breathing
Temp: 36.5C
Bp:120/80
RR:- 14
bpm
Pr:78
O2 sat-75

Nursing
Diagnosis
Ineffective
breathing
pattern
related to
pain

Objectives

Intervention

Rationale

Evaluation

After 8
years of
nursing
interventio
n the
patient will
be able to
establish
normal,
effective
respiratory
pattern as
evidenced
by absence
of cyanosis
and other
s/s and
other

Determine
presence of
factors/physi
cal condition
as noted.

Related
factor that
could cause
breathing
impairment
s

After 8 hrs
of nursing
interventio
n:
Goal met.

Auscultate
chest, note
rate and,
depth of
respiration,
types of
breathing
pattern.
Administer
O2 at lowest
concentratio
n indicated
and
prescribe
respiratory
medication

Monitor
pulse
oximetry, as
indicated.

Encourage
slower/deep
er
Respiration,
use of
pursed-lip
technique.

To evaluate
presence /
character
of breath
sounds and
secretions

For
manageme
nt of
underlying
pulmonary
condition,
respiratory
distress
and
cyanosis
To verify
maintenanc
e/
improveme
nt in O2
saturation
T of the
situationo
assist client
in taking
control