NURSING CARE PLAN

Name: Camille Sue-Ann Renné

 Howard University
College of Pharmacy, Nursing and Allied Health Sciences
Division of Nursing
Medical – Surgical Nursing II
NURS 423
Nursing Care Plan
Assessment Nursing Diagnosis Goals
- Client presented with pain in (1) Acute Pain related - The client will report
right leg which first started one to impaired venous any changes in pain to
day prior to admission. blood flow and the nurse every 3 hours.
- The client stated that “the pain inflammation as - The client will report
intensified a couple hours after evidenced by whether pain was
it started and was accompanied complaints of pain controlled 30 minutes
by swelling.” -rating pain as 8 on a after receiving pain
- Verbal pain rating in right leg 10-point scale, and medication.
at calf region is 8/10. presence of slight - The client will
swelling in right leg. implement the use of
non-pharmacologic
techniques such as
relaxation, music
therapy, warm
compresses and
distractions before, after,
and during expected
painful activities as well
as pharmacologic
treatment for pain.
Interventions Evaluation
- Monitor the client - The client reported
and assess for pain an increase in comfort
frequency, quality, and a decrease in pain
intensity or severity. 30 minutes after the
- Assess the client’s medication was
pain 30 minutes after administered.
she is given pain - Pain level was now
medication. 5/10.
- Review with the - Client seemed more
patient and her relaxed.
family, some non- - Goal met.
pharmacological
interventions that
may assist in
controlling pain.
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- S/P abdominal hernia repair.
- Client has a post-op surgical
incision on her abdominal area.
- Surgical dressing is dry and
intact with no swelling or
discharge present.
- Urine output, lung sounds and
temperature W/I normal
findings.
- Client has ↓ ROM in right leg
compared to her left leg and
complains of pain in right leg.
(2) Risk for infection - The client will be free - Monitor the client’s - The patient remained
secondary to surgery from infection at as vital signs, skin free from infection.
related to altered skin indicated by normal vital temperature, surgical - Goal met.
integrity as evidenced signs, warm dry skin, dry dressing, lung
by surgical incision and intact surgical sounds/breath sounds,
and possible presence dressing, clear breath and urine – for
of hospital sounds, and clear yellow normal readings –
environmental urine. encourage post-op
pathogens. deep breathing.
(3) Impaired physical - The client will be given - Medicate the client - The client showed
mobility, related to her pain medication for before attempting improvement in her
pain of right leg maximum comfort before ambulation and mobility and was able
secondary to altered attempting to get out of performing her ADLs to ambulate into the
tissue perfusion as bed and performing on mornings. chair and carry out her
evidenced by ADLs. - Teach the client the ADLs without any
difficulty in getting - The client will importance of being complaints after
out of bed and demonstrate measures to safety while receiving her pain
ambulating. increase mobility before ambulating. medication.
discharge. - Teach the client the - The client remained
- The client will importance of free of falls.
independently preventing falls – and - The client verbally
demonstrate safe and the risks and injuries explained proper
effective transfers, associated with falls. safety measures and
ambulation and mobility the importance of
with the absence of falls preventing falls.
before discharge. - Goal met.
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- Client has acknowledged the
severity of her diagnosis
however she is not aware of the
consequences related to her
lifestyle and DVT.
(4) Knowledge - The client will be able
Deficit related to lack to describe the basic
of sufficient disease process related to
information regarding DVT before discharge.
diagnosis and - The client will be able
reduction of risk to describe self-care
factors as evidenced responsibilities and
by risky lifestyle lifestyle changes related
(smoking, sedentary to preventing DVT
lifestyle, and poor before discharge (E.g.
dietary habits.) smoking cessation)
-The client will be able to
describe the benefits of
exercise in her disease
management before
discharge.
- The client will be able
to identify ways of
improving her health and
preventing DVT before
discharge.
- The client will express
the ability to identify if a
DVT has recurred by and
the importance of
seeking immediate
medical assistance.
- Provide written - The client stated that
documents or offer she would try her best
the client to view a to stop smoking by
documentary that firstly reducing the
would teach her number of cigarettes
about her disease – she smoked every
and explain to her week.
that smoking - The client verbally
cessation, a low-fat communicated that “I
diet, and regular will try to purchase a
exercise can help in treadmill to use in my
reduce the occurrence home.”
of DVT. - Client stated “I will
- Teach the client try to maintain a low-
how to choose low- fat/ low-sodium diet, I
fat/low-sodium foods would check the food
by reading the food labels before
labels and the various purchasing them, and I
ways of preparing will stay away from
healthy food (E.g. – fried foods because
bake, broil and steam they can cause my
foods instead of arteries to become
deep-frying.) clogged.”
- The client will state - The client carried out
how she can identify a returned
the recurrence of a demonstration on how
DVT by dorsiflexing to check for the
her feet to see recurrence of a DVT
whether she by dorsiflexion.
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- Client is not aware of the side
effects related to her medication
for DVT.
- Client was unable to state the
effects of her medication and
the changes in her diet
necessary while taking her
medication when asked.
experiences calf pain. - Goals met (except
video & documents).
4) Knowledge Deficit - The client will be able - Provide written -The client verbally
related to lack of to describe the side documents or offer stated the ways of
information about her effects related to her her to view a looking out for
medication as DVT medication before documentary that possible signs of the
evidenced by not discharge. would teach her adverse effect of
being able to list the - The client will about the possible excessive bleeding
side effects of her acknowledge that side effects of her related to her
medication, the bleeding is the single anticoagulation anticoagulation
contraindications of most dangerous side medication – and medication.
eating certain foods effect of her medication explain to her the - The client stated that
and the ways to and she would be able to importance of she would check her
reduce bleeding verbally explain the signs identifying these side skin for bruising,
episodes. of bleeding before effects and seeking check her urine and
discharge. immediate medical stools for blood or any
- The client will be able assistance. pinkish tint.
to list the foods that she - The client will be - The client explained
should not able to know signs of that she would stay
bleeding. away from green leafy
- The client will vegetables because
explain that she will they will counteract
avoid green leafy the effects of her
vegetables because medication.
they are high in - Goals met (except for
Vitamin K which showing a video or
reverses the providing informative
anticoagulation documents to the
effects of her client).
medication.