Domine, Keziah Mei D.

BSN IV-1

Mr. Alexander Bactad Clinical Instructor NURSING CARE PLAN

ITRMC, Surgical Ward 3pm- 11pm, 7th Rotation

Patient: R.C.M. Problem: Status post Craniectomy Potential Problem: Risk for Infection ASSESSMENT Subjective: N/V Objective: indwelling foley catheter incision on right temporoparietal Albumin 9/30/08 2.5 L WBC 9/30 8.4 and 10/02 10.7 normal Hgb 9/30 11.3 L 10/02 9.7 L Rashes on the left arm Multiple abrasions secondary to mauling V/S T = 38.3 DIAGNOSIS Risk for infection related to inadequate primary and secondary defences. PLANNING After 8 hours of nursing interventions, the client will remain free of infection.

Age: Diagnosis:

17 years old Epidural Hematoma Right Temporoparietal

IMPLEMNTATION INTERVENTION RATIONALE Independent: Monitored vital Reflective of signs inflammatory process and to evaluate the presence of infection Promoted thorough handwashing by support system and caregivers Provided meticulous skin and oral care Encouraged frequent positioning Prevents cross contamination

EVALUATION Goal met if: After 8 hours of nursing interventions, the client remained free from infection as evidenced by normal levels of secondary defences and maintained skin integrity Goal partially met if: After 8 hours of nursing intervention, the patient remain free of infection but slight elevation on secondary defences (WBC) and presence of

Reduces risk of skin or tissue breakdown and infection Promotes ventilation of all lung segments and aids in

PR = 115 bpm RR = 25 bpm

mobilizing secretions to prevent pneumonia Maintained adequate oxygenation via face mask and maintain proper IV regulation Assist in liquefying and humidifying secretions to facilitate expectoration and prevent stasis of body fluids.

signs of infection on the skin (rubor, pallor, swelling) Goal not met if: After 8 hours of nursing intervention, the client manifested signs and symptoms of inflammation and elevated secondary defences.

Dependent: Administered antibiotic as prescribed

Given ampicillin sulbactam, and cefuroxime, that inhibits the bacterial cell growth and preventing infection.

NURSING CARE PLAN Patient: Problem: Actual Problem: ASSESSMENT Subjective data: N/A Objective data: skin warm to touch increase respiratory rate: 25 bpm flash skin restlessness dry skin diaphoresis seizure activities V/S: To = 38.3oC RR = 25 bpm PR = 115 bpm R.C.M. Status post Craniectomy Hyperthermia DIAGNOSIS Hyperthermia related to trauma secondary to surgical procedure on craniectomy as evidenced by temperature of 38.3oC PLANNING After 1 hour of nursing interventions, the patient body core temperature will decrease within normal range from 38.3oC to 37.5oC Age: Diagnosis: 17 years old Epidural Hematoma Right Temporoparietal

IMPLEMNTATION INTERVENTION RATIONALE Independent: monitor heart vital signs are rate and taken to be the rhythm, pulse bases of rate and nursing temperature intervention and to evaluate hyperthermia identify to assess underlying contributing cause factors promote to reduce body surface cooling temperature by means of TSB promote safety for safety by raising side measures rails during seizure activities assess any to assess any other signs and possible symptoms complication Remove excess These decrease clothing and warmth and covers. increase evaporative cooling

EVALUATION After 1 hour of nursing interventions, the patients temperature decreased to normal range from 38.3C to 37.5C

 Educate and advise support system (relative) to do TSB when patient feels hot. - Luke warm water only. - Make sure that armpits and groins were included in doing TSB. Dependent 10. Provide antipyretic (paracetamol) medications as prescribed.

Teaching the Support system the right way to do TSB will help in knowing what to do in case the patients temperature increases

This drug inhibit the prostaglandin and lowers fever.