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Nursing Care Plan Essay

992 words - 4 pages

Putong, Jonathan
4 y/o
Post incision and drainage
Cues | Diagnosis | Inference | Plan of care | Nursing Interventions | Rationale | Evaluation |
Subjective:“ sakit sugat ko dito ma” as verbalized by the patientObjective: * Localized ...view middle of the document...

* Facial grimace ceased * Irritability & guarding behavior settled. * Episode of crying is diminished | Independent * Established rapport * Monitor vital signs * Inform client and his watcher about pain relief measures, including how long it takes to achieve relief and how long to expect relief to last. * Emphasize safety precaution measures to the patient and to the watchers * Encourage diversional activities such as slow, controlled deep breathing and coughing exercises. * Provided a quiet and comfortable environment. * Encourage the patient to take adequate sleep * Provide comfort measures such as change of position as possible. * Discuss to the patient and watcher the importance of intake of foods rich in Vit. C * Instruct the watcher and the patient regarding the importance of proper hygieneDependent * Administer pain reliever such as analgesics and antibiotics such as penicillin as prescribed by the physician. | * To gain trust and enhance the ability to participate in activities * Provide baseline data. Alterations from normal may be signs of infection. * Enhances trust and therapeutic relationship. * Providing information about precaution measures promotes safety * Alleviate pain and anxiety, promote relaxations. Decreased lung capacity and decreased cough efficiency are predisposing factors to respiratory infection. * Sustain a stress-free feeling to the patient and promotes effective coping to manage discomfort. * This promotes healing by reducing basal metabolic rate and allowing oxygen and nutrients to be utilized for tissue growth, healing and regeneration * Position changes promote comfort, reduce muscle tension and relieve pressure. * Foods rich in Vit. C promotes faster wound healing * Improper hygiene promotes the recurrence of infection * NSAID’s have an analgesic and anti inflammatory effect. Antibiotics are used to treat & prevent infections caused by susceptible pathogens in skin structure infections | Goal met:After 6 hours of nursing interventions, the pain was alleviatedAs evidenced by: * Pain occurrence can be felt intermittently and minimally * Facial grimaced ceased * Irritability & guarding behavior settled. * Episode of crying is diminished |
Putong, Jonathan
4 y/o
Post incision and drainage
Cues | Diagnosis | Inference | Plan of care | Nursing Interventions | Rationale | Evaluation |
Subjective:“ May tahi ako dito oh (post auricular area)” as verbalized by the patientObjective: * Disruption of skin surface at post auricular area * Incision is 5 mm in diameter * Localized erythema and edema * (+)Pruritus at the site of the incision * (+)pain * (+) VS normal T= 36.8 ‘ c PR= 77 RR= 25 | Impaired tissue integrity related to tissue trauma secondary to incision and drainage as manifested by * Disruption of skin surface at post auricular area * Incision of 5 mm in diameter * Localized...

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