POTENTIAL NURSING CARE PLAN ASSESSMENT EXPLANATION OF THE PROBLEM

STO: Within 1 hour of effective nursing intervention the client ill be able to identify individual area of weakness or needs and identify personal resources that can provide assistance. Planned time for listening to the clients or SO feelings and concerns. LTO: Within 3 days of effective nursing

OBJECTIVES
Independent: Performed or assisted with meeting clients needs when he is unable to meet own need.

NURSING INTERVENTIONS
Assessed skin. Noted color, turgor, and sensation. Described

RATIONALE
Establishes comparative baseline opportunity intervention. providing for timely

EVALUATION
Subjective: maglisud man gud ko ug lihok as verbalized by the patient

Subjective:

May mga sugat ako. as verbalized by the patient.

and measured wounds and observed changes. Maintaining clean, dry Demonstrated good skin hygiene,
Reviewed and modify program periodically to accommodate changes clients abilities. Objective: -age: 80 y/o -with NGT, FBC, colostomy bag -O2 Saturation: 92% -edema on the upper and lower extremities -inability to move -inablity to pick-up clothing -inablity to take a bath -inabilty to get commode -appears weak

skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin. Skin friction caused by

e.g.,

wash

intervention the client will be able to demonstrate techniques and lifestyle changes to meet self-care needs and perform self- care activities within level of own ability. Supported client in making health related decisions and assists in developing self-care practices and goals that promote health.

thoroughly and pat dry carefully.

Instructed maintain clothes, shirt).

family clean,

to dry

stiff or rough clothes leads fragile increases infection. Improved nutrition and to irritation skin risk of and for

preferably

(+) pain

cotton fabric (any TCollaborative: Administered intra lipid 500cc @ 42cc/hr, as indicated.

Emphasized importance of adequate nutrition and fluid intake.

hydration will improve skin condition. Providing the family with

Demonstrated

to

the

alternative

solution

family members on how to make as a guava decoction to apply to the wound alternative disinfectant. Instructed family to clip and file nails regularly.

assists them in optimal healing with less expensive resources. Long and rough nails increase risk of skin damage.

Wound dressings protect Provided and applied wound dressings carefully. the wound and the surrounding tissues.

POTENTIAL NURSING CARE PLAN ASSESSMENT O>febrile, 38.5 >swelling surgical incision >redness noted on the surgical wound > wet surgical dressing > weakness in appearance >irritable >restless Nursing diagnosis: Risk for infection related to traumatized tissue secondary to post prostatectomy. EXPLANATION OF THE PROBLEM Prostatectomy Surgical incision Tissue trauma OBJECTIVES STO: Within 8hours of nursing interventions, the patient will be able to identify proper actions to prevent possible occurrence of infection and verbalize understandings of individual causative or risk factors of infection. LTO: After 2 days of nursing interventions, the patient will achieve timely wound healing, be afebrile, and identify interventions to prevent or reduce infection. NURSING INTERVENTIONS Dx: > Monitor vital signs. RATIONALE EVALUATION STO: After 8hours of nursing intervention, the patient will be able to identify proper actions to prevent infection and verbalize understandings of individual causative risk factors of infection.

Opening of tissue

Possible Site of entry of pathogens causing infection

> observe for localized Signs of infection at insertion sites and at wound site > to note presence of > assess surgical incision infection and wound complications Tx: >Establish rapport. > To gain trust and cooperation. > Assist patient on > for patient not to strain comfortable position. self. > maintain sterile technique > to reduce or correct in changing wound existing infection risk dressing factors. >perform TSB > Acknowledge patients question regarding infection cause and control >Give due antibiotics > to address fever > gives knowledge and background to patient regarding the cause and effects of infection

> vital signs are important baseline data because it proves possible infection > to assess causative and contributing factors of infection

Risk for infection

LTO: After 2 days of nursing interventions, patient will be able to achieve timely wound healing, be afebrile and identify interventions to prevent or reduce infection such as proper cleaning of wound aseptically.

> Helps prevent infection. Edx:

> Encourage on the following: - to increase fluid intake. - to take rest and sleep

> Keep fluid and electrolyte balance of the body > helps the patients body to regain strength

>emphasize necessity of taking antibiotics > for patient to cooperate in taking meds for infection control and prevention > instruct patient and significant others on proper prevention of infection > to promote wellness and prevent infection

ACTUAL AND POTENTIAL NCP

Patients case: PROSTATECTOMY

Submitted to: Mr. Alimbuyao, Jeffrey Submitted by:

Buangan, Jervise July 3, 2008