Sei sulla pagina 1di 8

NURSING CARE PLAN

Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation


Explanation
Subjective: Acute pain Short term: Independent: Short Term:
“Masakit kapag related to post- Vehicular Accident
gagalaw ako, tapos operation Within 8hrs of nursing  Perform pain  To investigate, or After 8 hours of
parang tumitibok-tibok incision intervention, the assessment monitor changes nursing intervention,
yung mukha ko.” secondary to patient will: each time pain from the previous goal was partially
Subconjunctival Direct blow on the occurs reports met as evidence by:
Character: Hematoma Left left frontal area  Verbalize methods
 Throbbing pain eye, frontal that provide relief.  Monitor vital  Can be altered when  Verbalized
bone fx signs the patient is in pain methods that
Onset: extending to the  Follow prescribed (Casapalmera.com) provide relief.
 Post-Operation orbital roof, Break in continuity pharmacological
(November 12, greater wing of of the bone regimen  Pain may result in  Followed
2018) sphenoid bone  Provide quiet fatigue, which may prescribed
and squamosal  Demonstrate use environment result in exaggerated pharmacological
Location: part of left of relaxation skills pain. A peaceful and regimen
 Left frontal area temporal bone; Small blood vessels and diversional quiet environment
multiple facial in the bone activities as may facilitate rest.  Demonstrated
Duration: bone fracture ruptures indicated for use of
 Continuous individual situation Stress increases HR relaxation skills
pain and which make you and diversional
getting worse  Report pain is breathe faster and activities as
when moving Surgery controlled from tightens muscles, in indicated for
8/10 to the scale addition to this individual
of 3/10 which can stress can cause situation
Severity: be ignored by the agitation ad anxiety
 Using the Tissue patient (Based on which is known to  Reported pain
Universal Pain Injury/Inflammatory the Universal Pain intensify feelings of was controlled
Assessment Cell Assessment) from 8/10 to
Tool, the scale pain 3/10 which can
is 8/10-Severe; (Verywellhealth.com) be ignored by
Interferes his  Absence of the patient
basic needs. irritability (Based on the
Sense by  Instruct, or  Exercises were Universal Pain
Pattern: Nociceptor  Coordination encourage use effective in reducing Assessment)
 Moving (even between him and of breathing the pain experienced
just for a little) the nurse (and relaxation due to various
makes it worse also his mother) exercise factors on the first
and relieved, or Converted to and second  Less
controlled when electro chemical  Absence of facial postoperative days irritability
given pain signals grimace (source: Effect of
medication. Relaxation Exercises  Coordination
 Absence of eye on Controlling between him
Associated factors: lackluster Postoperative Pain and the
The pain affects: Transmitted to 2012) nurse (and
spinal cord by  Absence of also his
 The current Dorsal Root moaning  Encourage  Divert focus from mother)
ADLs of the Ganglia diversional pain—and since the
patient – Fully activities patient was fond of  Less Eye
Dependent (watching TV, using his cellphone lackluster
(Score: 5) reading) for Facebook.
Brain  Less Facial
Grimace
Objective: Dependent:
Incision:  Absence of
Acute Pain  Use of  Reduces pain Moaning
 Irritated analgesic
medications:
 Self-Focused
>>Tramadol 50mg  Unknown. Thought
 Eye lackluster IV q 8 for severe to bind to opioid
pain receptors and inhibit
 Facial Grimace re uptake of
norepinephrine and
 Moaning serotonin
>>Diclofenac Na  May inhibit
75mg IV q 8 prostaglandin
 Suture: synthesis, to
 7 stitches produce
on the left inflammatory,
eyebrow analgesic, and
 5 stitches antipyretic effects
suborbital
 3 stitches
cringodental

VS:
 T: 37 C
 P: 68 bpm
 R: 14 cpm
 BP: 120/80
mmHg
Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation
Explanation

Objective: Risk for Impaired skin Short term: Independent: Short term:
infection integrity
 Suture: related to After 2 hours of  Monitor vital signs  Inflammation, purulent After 2 hours of
 7 postoperative nursing and watch out for drainage, erythema and nursing
stitches surgical intervention the any signs of fever may reflect intervention, goal
on the incision patient and the SO infection developing infection was met. The
left secondary Open portal for will be able to: patient and the
eyebrow
Multiple facial pathogens  Verbalize One purpose of a fever is SO were able to:
bone fracture understand thought to be raise the  Verbalized
 5
ing about body’s temperature understan
stitches
infection enough to kill of certain ding about
suborbita control bacteria and viruses’ infection
l Increased  Demonstrat sensitive to temperature control
 3 susceptibility e behaviors changes  Demonstr
stitches to infection to prevent (Sceience.howstuffworks ated
cringode and reduce .com) behaviors
ntal the risk of to prevent
infection  Inspect dressings  Early detection of and
 Intact Risk for and wound. Note developing infection reduce the
dressing infection Long term: characteristics of provides opportunity for risk of
drainage timely intervention and infection
VS: After 3-5 days of prevention of more
 T: 37 C nursing serious complications Long term:
intervention the
 P: 68 bpm patient will:  Maintain aseptic  Aseptic technique  To be
 R: 14 cpm  Be free technique with any decreases the chances evaluated
from any procedures. of transmitting or
 BP: 120/80 signs Provide routine spreading pathogens to
related to wound care, as the patient
mmHg
infection appropriate
 Practice proper  This minimizes the risk of
hand hygiene and contamination and
teach the patient development of infection
and SO to do so

Dependent:

 Administer antibiotics  Antibiotics can be used


as ordered: as a prophylactic
treatment

 Cefuroxime axetil  Inhibits cell wall


500mg/ tab, 1 tab synthesis, promoting
TID osmotic instability;
usually bactericidal

 Mupirocin  Inhibits bacterial protein


ointment BID for synthesis by reversibly
wound care and specifically binding
to bacterial isoleucyl
transfer-RNA synthetase

 Tobramycin eye  Thought to inhibit protein


drop q 4 OS synthesis; usually
bactericidal
Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation
Explanation
Subjective: Disturbed Body Vehicular Short term: Independent: Short term:
“Baka matagal akong Image related Accident After 3 hours of nursing After 3 hours of
di lalabas ng bahay, to multiple intervention the patient  Acknowledge  Acceptance of these nursing intervention
nahihiya kasi ako” as facial stitches will be able to: and accept feelings as a normal the goal was partially
verbalized by the secondary to expression of response to what has met as evidence by:
patient. Head trauma Direct blow feelings. occurred facilitates
on the left  Seek information resolution. It is not helpful
frontal area and actively or possible to push patient  Seek
pursue growth before ready to deal with information
Objective: situation. Denial may be and actively
prolonged and be an pursue growth
PERSON Break in  Acknowledge self adaptive mechanism
 The patient continuity of as an individual because patient is not
had his eyes the bone who has ready to cope with  Acknowledged
closed during responsibility for personal problems. self as an
assessment. self. individual who
He was kicking  Support  Support verbalization of has
the foot of his Small blood  Will be able to verbalization of positive or negative responsibility
bed and vessels in positive or feelings. It is worthwhile to for self.
covering his the bone negative encourage the patient to
bandaged left ruptures Long term: feelings separate feelings about
eye. He was changes in body structure
not answering After 1 week of nursing or function from feelings
to the intervention the patient about self-worth.
questions Surgery will: Expression of feelings can
asked about enhance the patient’s Long term:
his  Verbalize coping strategies.
appearance. acceptance of self-  To be
Disturbed situation Evaluated
 Negative Body Image
feeling about
his body.
 High tolerance of  Be realistic and  This enhances trust and
 Eye lackluster frustration. positive during rapport between patient
treatments, in and nurse.
 Low frustration  Have a positive health teaching,
tolerance level feeling about his and in setting
body. goals within
 Irritability limitations.
 Absence of eye
 Suture: lackluster  Support the
 7 stitches patient in  These may help the patient
on the left identifying ways adjust to the current issue.
eyebrow of coping that
 5 stitches have been
beneficial in the
suborbital
past.
 3 stitches
cringodent  Teach the
al patient adaptive  Adaptive behaviors help
behavior (e.g., the patient compensate for
use of adaptive the actual changed body
equipment, structure and function.
wigs,
cosmetics,
clothing that
conceals the
altered body
part or
enhances
remaining part
or function, use
of deodorants).
Collaborative:  An approach where
 Cognitive irrational thoughts are
Behavioral recognized, analyzed and
Therapy restructured to more
rational self-talk, is
frequently used in planning
care to address body
image disturbance.

Potrebbero piacerti anche