NAME OF PATIENT: L.B.C. ST.

ANTHONY’S COLLEGE
AGE/SEX: 84/ Female NURSING DEPARTMENT
PERIOPERATIVE PHASE: Intraoperative Phase San Jose, Antique
OPERATION PERFORMED: Extra Capsular Cataract Extraction, Left eye

NURSING CARE PLAN

CUES NURSING
RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
GENERAL: INDEPENDENT:
OBJECTIVE: Disturbed Disturbed Sensory
sensory Perception is the After 4 hours of Monitor vital signs and report if To provide a baseline data for After 4 hours of
V/S taken as perception change in the amount nursing there are specific alterations. the monitoring of the Nursing
follows: related to or patterning of interventions, the condition of the patient. Interventions, the
local incoming stimuli patient will goal was met. The
T= 35.9 °C anesthetic accompanied by a maintain Assess the patient’s condition To make sure that all the patient was able to
P= 88 bpm effect diminished, usual/improved before, during, and after the preoperative meds given was maintain
RR= 18 cpm exaggerated, level of procedure. on full effect usual/improved
BP= 140/80 distorted, or consciousness, level of
mmHg impaired response to cognition, and Reorient client continuously when Reduces external stimuli consciousness,
02 Sat= 98% such stimuli. sensory function. emerging from anesthesia; confirm during hyperactive stage. cognition, and
that surgery is completed. sensory function.

SPECIFIC: Provide quiet and calm environment. To lessen patient’s anxiety.

Source:
Ackley, B.J., & After 1 hour of Provide safety measures (e.g. To prevent injuries. After 1 hour of
Ladwig, G.B. (2006). nursing adequate lighting, raised side rails, nursing
Nursing diagnosis interventions the etc.) interventions, the
handbook: A guide to patient will goal was met. The
planning care (7th demonstrate patient was able to
ed.). Singapore: absence of side demonstrate
Elsevier Pte Ltd. effects/adverse absence of side
reactions to effects/adverse
anesthetic agents. reactions to
anesthetic agents.

Student’s Name: ANGIE G. MANDEOYA BSN – 4 Clinical Instructor: JERRY V. ABLE, RN, MAN.
NAME OF PATIENT: R.H.T. ST. ANTHONY’S COLLEGE
AGE/SEX: 13/ Male NURSING DEPARTMENT
PERIOPERATIVE PHASE: Postoperative Phase San Jose, Antique
OPERATION PERFORMED: Herniorrhaphy, Right
NURSING CARE PLAN
CUES NURSING
RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
OBJECTIVE: GENERAL: INDEPENDENT:
Impaired tissue Impaired Tissue
V/S taken as integrity related Integrity is the After 4 hour of Monitor vital signs and report if To provide a baseline data for the After 4 hours of
follows: to post surgery damage to nursing there are specific alterations. monitoring of the condition of the Nursing
of the abdomen mucous interventions, the patient. Interventions, the
T: 36.3 °C. as evidenced by membrane, patient will be able goal was met. The
PR: 102 bpm sutures in the corneal, to: Assess skin. Note color, turgor, Establishes comparative baseline patient was able to:
RR: 22 cpm abdominal area. integumentary, and sensation. Describe and providing opportunity for timely
BP: 110/80 or subcutaneous 1. Maintain measure wounds and observe intervention. 1. Maintain
mmHg. tissues. wound intact. changes. wound intact.
O2 Sat: 100% 2. Demonstrate 2. Demonstrate
behaviors that Demonstrate good skin hygiene. Maintaining clean, dry skin behaviors
reduce Provide and apply wound provides a barrier to infection. that reduce
Source: tension on dressings carefully. tension on
Ackley, B.J., & suture line. suture line.
Ladwig, G.B. Provide routine incisional care Wound dressings protect the
(2006). Nursing being careful to keep dressing wound and the surrounding
diagnosis SPECIFIC: dry and sterile. tissues.
handbook: A After 1 hour of
guide to planning After 1 hour of Inform patient of the purpose of To assess and avoid infection. nursing
care (7th ed.). nursing self-care practices. To increase compliance and to interventions, the
Singapore: interventions the provide basic knowledge on how goal was met. The
Elsevier Pte Ltd. patient will verbalize to manage wound. patient was able to
understanding of verbalize
condition and Keep the side rails up always. To ensure patient’s safety. understanding of
causative factors of condition and
infection. Maintain quiet, calm To help patient feel comfort and causative factors of
environment relax. infection.

Student’s Name: ANGIE G. MANDEOYA BSN – 4 Clinical Instructor: JERRY V. ABLE, RN, MAN.
NAME OF PATIENT: J.C.D. ST. ANTHONY’S COLLEGE
AGE/SEX: 58/ Male NURSING DEPARTMENT
PERIOPERATIVE PHASE: Preoperative Phase San Jose, Antique
OPERATION PERFORMED: Below Knee Amputation, Left Leg

NURSING CARE PLAN

CUES NURSING
RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
INDEPENDENT:
OBJECTIVE: Altered sensory/ Altered GENERAL:
thought sensory/thought Monitor vital signs and report if To provide a baseline data for
V/S taken as perception process is After 4 hours of there are specific alterations. the monitoring of the condition After 4 hours of
follows: related to the erroneously nursing of the patient. Nursing
use of anesthetic attributed to patients Interventions, the Interventions,
T: 36.7 °C. agent undergoing surgery. patient will regain Confirm that surgery is completed. Support and assurance will the goal was
PR: 69 bpm Confusion in these usual level of Reorient continuously. help alleviate anxiety as met. The
RR: 20 cpm kind of patients can consciousness. patient regains consciousness. patient was able
BP: 150/90 be caused by to regain usual
mmHg. multiple factors or a Speak in normal, clear voice without It is thought that the sense of level of
O2 Sat: 100% single factor such as shouting. Minimize discussion of hearing returns before patient consciousness.
anesthetic agent, SPECIFIC: negatives within patient’s hearing. appears fully awake, so it is
medication side important not to say things
effects, etc After 1 hour of that may be misinterpreted.
nursing After 1 hour of
interventions, the Evaluate sensation and/or Return of function following nursing
Source: patient’s vital signs movement of extremities and trunk local or spinal nerve blocks interventions,
Ackley, B.J., & will still be in as appropriate. depends on type or amount of the goal was
Ladwig, G.B. (2006). normal level. agent used and duration of met. The
Nursing diagnosis procedure. patient’s vital
handbook: A guide to signs are still in
planning care (7th Keep the side rails up always. To ensure patient’s safety. its normal level
ed.). Singapore: as evidenced
Elsevier Pte Ltd. Maintain quiet, calm environment. To help patient feel comfort by:
and relax.

Student’s Name: ANGIE G. MANDEOYA BSN – 4 Clinical Instructor: JERRY V. ABLE, RN, MAN.
NAME OF PATIENT: J.P. ST. ANTHONY’S COLLEGE
AGE/SEX: 46/ Male NURSING DEPARTMENT
PERIOPERATIVE PHASE: Preoperative Phase San Jose, Antique
OPERATION PERFORMED: Ray Amputation of 2nd & 5th toe, Right
NURSING CARE PLAN
CUES NURSING
RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: INDEPENDENT:
Anxiety Anxiety is a vague GENERAL:
“Nakulbaan related to the uneasy feeling of Monitor vital signs and report if To provide a baseline data for the
ako kun anu surgical discomfort or dread After 2 hours of there are specific alterations. monitoring of the condition of the After 4 hours of
matabo experience accompanied by an nursing patient. Nursing
kanakun sa (anesthesia, autonomic response intervention, the Interventions,
silud ka OR”, pain) and the (the source often client will be able to Provide accurate information To know his own perception about the goal was
as verbalized outcome of nonspecific or appear relax and about the situation of the client the upcoming surgery. met. The
by the sister surgery. unknown to the report anxiety is and reasons for surgery patient was able
of the patient. individual); a feeling reduced to a to appear relax
of apprehension manageable level. Encourage client to acknowledge It can lessen or minimize the fear and report
OBJECTIVE: caused by anticipation and to express feelings through that client is experiencing. anxiety is
of danger. It is an sharing or other means of reduced to a
>cannot alerting signal that coping. manageable
maintain eye warns of impending level.
to eye contact danger and enables SPECIFIC: Provide comfort measures such To avoid the occurrence of
> Narrowed the individual to take as calm and quiet environment. precipitating factor that may
focus measures to deal with After 1 hour of Keep the side rails up always. increase the anxiety.
the threat. nursing After 1 hour of
>V/S taken as interventions the Be available to client for Knowing that someone nursing
follows: client will be able to listening and talking. understands what he feels it can interventions,
T: 36.4 °C. understand the help to at least lessen the burden the goal was
PR: 77 bpm Source: procedure she is and show support. met. The
RR: 22 cpm Ackley, B.J., & Ladwig, going to expect patient was able
BP: 120/90 G.B. (2006). Nursing inside the OR. to understand
mmHg diagnosis handbook: A the procedure
guide to planning care she is going to
(7th ed.). Singapore: expect inside
Elsevier Pte Ltd. the OR.

Student’s Name: ANGIE G. MANDEOYA BSN – 4 Clinical Instructor: JERRY V. ABLE, RN, MAN.
NAME OF PATIENT: M.V.Q. ST. ANTHONY’S COLLEGE
AGE/SEX: 34/ Female NURSING DEPARTMENT
PERIOPERATIVE PHASE: Preoperative Phase San Jose, Antique
OPERATION PERFORMED: Pelvic Laparotomy
NURSING CARE PLAN
NURSING
CUES DIAGNOSI RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
S
SUBJECTIVE: INDEPENDENT:
Anxiety Anxiety is a vague GENERAL:
“Nakulbaan related to uneasy feeling of Monitor vital signs and report if To provide a baseline data for the After 4 hours of
ako kun anu unfamiliarit discomfort or dread After 2 hours of there are specific alterations. monitoring of the condition of the Nursing
matabo y with the accompanied by an nursing patient. Interventions, the
kanakun sa surgical autonomic response intervention, the goal was met. The
silud ka OR”, procedure (the source often client will be able Establish a therapeutic To establish trust and showing patient was able
as verbalized as nonspecific or unknown to appear relax and relationship, conveying empathy interest. to appear relax
by the sister evidenced to the individual); a report anxiety is and unconditional positive and report
of the patient. by increased feeling of apprehension reduced to a regard. anxiety is
blood caused by anticipation manageable level. Identification of specific fear reduced to a
OBJECTIVE: pressure of danger. It is an Validate source of fear. Provide helps patient deal realistically manageable level.
>Restlessness alerting signal that accurate factual information. with it.
>Facial warns of impending SPECIFIC:
Flushing danger and enables the Provide accurate information To know his own perception
> Narrowed individual to take After 1 hour of about the situation of the client about the upcoming surgery. After 1 hour of
Focus measures to deal with nursing and reasons for surgery nursing
the threat. interventions the interventions, the
>V/S taken as client will be able Encourage client to acknowledge It can lessen or minimize the fear goal was met. The
follows: to acknowledge and to express feelings through that client is experiencing. patient was able
T: 36.7 °C. feelings and sharing or other means of coping. to acknowledge
PR: 69 bpm Source: identify healthy feelings and
RR: 20 cpm Ackley, B.J., & Ladwig, ways to deal with Provide comfort measures such To avoid the occurrence of identify healthy
BP: 150/90 G.B. (2006). Nursing them as evidenced as calm and quiet environment. precipitating factor that may ways to deal with
mmHg. diagnosis handbook: A by decreased blood Keep the side rails up always. increase the anxiety. them as
guide to planning care pressure. evidenced by
(7th ed.). Singapore: Be available to client for listening Knowing that someone decreased blood
Elsevier Pte Ltd. and talking. understands what he feels it can pressure.
help to at least lessen the burden
and show support.

Student’s Name: ANGIE G. MANDEOYA BSN – 4 Clinical Instructor: JERRY V. ABLE, RN, MAN.
NAME OF PATIENT: J.D. ST. ANTHONY’S COLLEGE
AGE/SEX: 58/ Male NURSING DEPARTMENT
PERIOPERATIVE PHASE: Preoperative Phase San Jose, Antique
OPERATION PERFORMED: Ray Amputation of 2nd & 5th toe, Right
DRUG STUDY
Name of Drug
Classification and Mechanism Indication and Side Effects or
(Dosage, Route, Nursing Responsibilities
of Action Contraindication Adverse Reactions
Frequency, Timing)
Generic Name: Classification: Indication:  Dry Mouth  Check the physicians order.
 Drowsiness
Clonidine Hydrochloride Oral Antihypertensive; Management of all  Dizziness  Follow the 14 rights of medications
75 mcg/tab Centrally- acting drugs grades of hypertension.  Constipation

 Assess blood pressure and apical pulse before

Brand Name: Contraindication: initial dose. If systolic blood pressure is
Catapres <90mmhg or pulse is<60 bpm, withhold drug and
Contraindicated in notify physician.
Mechanism of Action: patients with known
Dosage: hypersensitivity to the  Monitor intake and output ratios and daily
Clonidine stimulates α2- active ingredient, weight, and assess for edema daily, especially at
75 mcg/tab adrenoceptors in the brain clonidine beginning of therapy. Report change in I&O ratio
stem which results in reduced hydrochloride, and in or change in voiding pattern.
sympathetic outflow from the patients with severe
Route: CNS, and a decrease in bradyarrhythmia
peripheral resistance, heart resulting from  Be sure to teach the patient to take this
Sublingual rate, BP and renal vascular either sick sinus medication same time each day, even if feeling
resistance. syndrome or AV block well. All routes of clonidine should be gradually
of second or third discontinued over 2-4 days to prevent rebound
Frequency: degree. hypertension.
Stat

Timing:
10:30 AM

Student’s Name: ANGIE G. MANDEOYA BSN – 4 Clinical Instructor: JERRY V. ABLE, RN, MAN.