Polytechnic College of Davao Del Sur Mcarthur Highway, Digos City Nursing Care Plan

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POLYTECHNIC COLLEGE OF DAVAO DEL SUR

McArthur Highway, Digos City

NURSING CARE PLAN

Name:_Dave Reynold Englis________________________________ Attending Physician:________________________________________


Age:__58____Sex:____M____Civil Status:___Married_______ Diagnosis:________________________________________________
Occupation:__________________Religion:_____________________ ________________________________________________________
Address:_________________________________________________ Chief Complaint:___________________________________________
Ward:________Room No:____________Bed No:________________ Date of Admission:_________________________________________

DATE/ CUES NEEDS NURSING SCIENTIFIC GOALS NURSING RATIONALE EVALUATION


TIME DIAGNOSIS BASIS OBJECTIVES INTERVENTION
CRITERIA
07/14/2022 S: P Risk for Vulnerable to At the end of my INDEPENDENT
“Na operahan mn ko H infection invasion and 8 hours span of NURSING
gahapon maam kay na Y related to multiplication of care, the patient INTERVENTION
disgrasya man ko” S tissue pathogenc *Note sign and *To help the patient
will be able to
I distruction; organisms, which symptoms and risk indetify the presence of
O: O invasive may compromise factor for possible risk factors
a. Verbali
* L procedure health. occurence of
zed
*Post- debridement O infection in the
underst
@ right foot noted G Reference: incision site.
anding
*weak apperance I Jutdith M.
about
noted C Wilkinson & *Cleasing,
the
Laurie Barcus. monitoring and *to help speed up the
infectio
N promotion of
Nursing n healing process
E healing of the
Diagnosis b. Willing
E wound
Handbook 11th ness to
D
Edition, p. 464 follow
S *Observe
up *to prevent infection
performance of
regimen
personal hygiene
practices
*To give the client the
*Make health
teaching especially appropriate knowledge
in identification of and understanding about
environmental risk the environmental risk
that could add up factor.
to the infection

DEPENDENT
NURSING
INTERVENTION
*Administer *To prevent medication
medication as error
ordered by the
physician and with
the permssion from
the clinical
instructor

COLLABORATIV
E
INTERVENTION
*Confer to *To give appropriate
appropriate post operative treatment
medical care
provider such as
doctors

Name:____________________________________________________Year &Sec:__________________Group No:_______________Rating:______________


Reference:_______________________________________________________________________________________________________________________
Criteria: Promptness (5%) Objectives of care(10%)
Format/Neatness(15%) Nursing Action(40%)
Nursing Diagnosis(15%) Clinical Instructor:___________________________________

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