NURSING CARE PLAN 5

1.    Impaired skin integrity related to full thickness as evidence by destroyed of tissue.

Goal: Patient will demonstrate tissue regeneration.

No.	Nursing Intervention	Rationale
1.	Assess the area of impaired skin integrity.	For further planning.
2.	Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain and other signs of infection.	To prevent complications.
3.	Do dressing twice per day.	Encourage rehabilitation of skin.
4.	Provide diet that high in protein.	To help build new cell tissue.
5.	Encourage patient to take more vegetables and fruits rich in vitamin D such as grapes, brinjal and purple spinach.	To promote the wound healing.
6.	Select a topical treatment that will maintain a moist wound-healing environment.	To avoid infection.

Evaluation: Patient’s skin integrity was recovered.

NURSING CARE PLAN 4

1.            Ineffective breathing pattern related to severe pain as evidenced by dyspnea.

Goal: Patient will breathed normally without using oxygen support.

No.	Nursing Intervention	Rationale
1.	Assess patient’s respiratory status.	To plan further treatment
2.	Monitor vital signs especially rate of respiration. Normal respiratory rate is 12 to 20 breaths/min in the adult.	To assess any abnormal changes
3.	Monitor breathing pattern and chest movement either shallow or deep.	To detect changes early
4.	Note abdominal breathing, use of accessory muscles, nasal flaring or lethargy.	The uses of external accessory muscle is indicator for dyspnea
5.	Monitor patient’s oxygen saturation and blood gases. Normal oxygen saturation is 90% to 100% while partial pressure of oxygen is 80% to 100%.	To know the level of oxygen in the blood
6.	Position the patient in an upright or Semi-Fowler’s position.	An upright position facilitated lung expansion.
7.	Administer oxygen as ordered.	Supplemental oxygen helps reduce hypoxemia and relieve respiratory distress
8.	Encourage the patient to take deep breaths.	To increase the expansion of the lung

Evaluation: Patient was able to breathe normally on his own. 

NURSING CARE PLAN 3

1.      Risk for infection related to surgical procedure at abdominal.

Goal: Patient will remain free from symptoms of infection such as redness, warmth, swelling, discharge and increased body temperature.

No.	Nursing Interventions	Rationales
1.	Assess site of wound surgery every day and report signs of infections such as redness, warmth, discharge and increased body temperature.	To observe any changes of wound and further treatment.
2.	Monitor temperature every 4 hours.	Fever is often the first sign of infection.
3.	Assess skin for color, moisture, texture and turgor.	The skin is the body’s first line of defense in protecting the body from infection.
4.	Monitor white blood cell (WBC) count.	An increasing WBC count indicates the body’s efforts to combat pathogens. Normal values are 4000 to 11 00/ mm3.
5.	Maintain or teach asepsis for dressing changes and wound care.	Use of aseptic technique decreases the chances of transmitting or spreading pathogens to the patient.
6.	Encourage fluid intake of 2000 to 3000 ml of water per day.	Fluid intake helps thin secretions and replaces fluid loss during fever.
7.	Encourage intake of protein foods.	Optimal nutritional status supports immune system responsiveness.
8.	Ensure patient’s appropriate hygienic care such as bathing and toileting.	Hygienic care is important to prevent infection.
9.	Limits the visitors during visiting hours.	Restricting visitations by individuals with any type of infection reduces the transmission of pathogens to the patient at risk of infection.
10.	Administer the use of antimicrobial drugs as ordered by doctor.	Antimicrobial is used to toxic to the pathogen or retard the pathogen’s growth.
11.	Teach the patient and family about the symptoms of infection that should be promptly reported to the doctor such as redness, warmth, swelling, tenderness or pain, new onset of drainage and increased body temperature.	Two thirds of wound infections occur after discharge.
12.	Instruct the patient to take the full course of antibiotics even the symptoms improve or disappear.	Not completing the entire course of the prescribed antibiotic regimen can lead to drug resistance in the pathogens and reactivation of symptoms.

Evaluation: Patient remains free of infection as evidenced by normal vital signs and absence of redness, warmth, discharge and increased body temperature from wounds

NURSING CARE PLAN 2

NURSING CARE PLAN 2
1.      Nausea and vomitting related to side effects of PCA(Patient-Controlled Analgesia) as evidenced by patient keep vomits.

Goal: Patient will reports diminished nausea and vomitting.

No.	Nursing Interventions	Rationales
1.	Assess the cause of nausea and vomiting.	Determining the cause of nausea and vomiting will guide the choice interventions to be used.
2.	Monitor nausea and vomiting characteristics such as duration, frequency, severity and precipitating factors.	A comprehensive assessment of the nausea and vomiting can help determine interventions to minimize the problems.
3.	Assist with oral hygiene every 2 to 4 hours if tolerated.	Nausea is often associated with anorexia and increased salivation. Oral hygiene will help promote comfort.
4.	Remove noxious odors from the surroundings such as perfumes or smelly odors.	Strong or noxious odors can contribute to nausea.
5.	Maintain fluid balance of patient in 2000 ml to 3000 ml of plenty water.	Adequate hydration has been shown to reduce the risk of nausea.
6.	Offer frequent, small amounts of foods that appeal to the patient.	This approach will help maintain nutritional status and for some patient, an empty stomach exacerbates the nausea.
7.	Encourage the patient to use non pharmacological nausea control techniques such as relaxation, music therapy or deep breathing.	These techniques have helped patient manage their nausea but they need to be used before nausea occurs or increases.
8.	Administer antiemetic such as Maxolon as ordered by doctor.	Most antiemetic act by raising the threshold of the chemoreceptor trigger zone to stimulation.
9.	Teach the patient to change positions slowly.	Sudden or gross movement may increase nausea.
10.	Teach patient to use PCA when the pain is feel.	Overdose uses of PCA may increase the severity of nausea.

Evaluation: Patient reports eliminations of nausea and vomiting.

NURSING CARE PLAN 1

NURSING CARE PLAN 1

1.      Acute pain related to surgical procedure as evidenced by patient’s pain score 6/10.

Goal: Patient’s pain score will be rating at 2 to 3 scale.

No.	Nursing Interventions	Rationales
1.	Assess pain characteristics such as: ·         Quality = sharp, burning, shooting. ·         Severity = 0-3 (mild pain).                4-7 (moderate pain).                8-10 (severe pain). ·         Location = anatomical descriptions. ·         Onset = gradual or sudden. ·         Duration = intermittent or continuous. ·         Precipitating factors.	Assessment of the pain experience is the first step in planning pain management strategies.
2.	Assess for the signs and symptoms associated with pain.	The patient in acute pain may have an elevated blood pressure, heart rate and temperature. The patient’s skin may be pale and cool to touch. The patient may be restless and have difficulty concentrating.
3.	Monitor patient’s response towards pain and pain management strategies.	Pain may be evaluated via effect of mood, emotion, restless and depression.
4.	Monitor the use of PCA in controlling the pain.	PCA is the IV infusion of an opiod through an infusion pump that is controlled by the patient. This allows the patient to manage pain relief within prescribed limits.
5.	Monitor possible PCA complications such as excessive sedation, respiratory distress, urinary retention, nausea and vomiting, constipation and IV site pain, redness and swelling.	Early assessment of complications is necessary to prevent serious adverse reactions to opiod analgesics.
6.	Provide complete rest in bed to facilitate comforts, sleep and relaxation.	The patient’s experienced of pain may become exaggerated as the result of fatigue.
7.	Encourage patient to use non pharmacological methods in managing the pain such as relaxation, music therapy and breathing exercise.	These techniques are used to bring about a state of physical and mental awareness and tranquility. The goal of these techniques is to reduce tension and subsequently reducing the pain.
8.	Administer appropriate pain relief method such as opiod analgesics (Ponstan, Cerebrex or Tramal) or local anesthetic agents as ordered by doctor.	Opiod may be administered orally, intravenously, systemically by PCA systems or epidural. Local anesthetic agents block pain transmission and pain in specific area. They are effective in managing mild to moderate pain.
9.	Instruct the patient to evaluate and report the effectiveness of measures used.	Pain relief strategies can be modified to promote more satisfactory comfort levels.
10.	Teach the patient about the purpose, benefits, techniques of use and action, need for IV line, other alternatives for pain control and need to notify the nurse of machine alarm and occurrence of untoward effects.	Effective pain management with PCA requires patient knowledge of how to use the equipment.

Evaluation : Patient was reports satisfactory pain control at a level less than 3 on a rating scale to 0 to 10.