COR JESU COLLEGE

Sto. Rosario, Tres De Mayo Digos City

Health Sciences Department

NURSING CARE PLAN

NAME: Diama, Valeriano AGE:24 y/o SEX: Male CIVIL STATUS: Married
RELIGION: Catholic DATE OF ADMISSION: 08/20/10
CHIEF OF COMPLAIN: depressed comminuted Fx left temporoparietal bone sec. to mauling IMPRESSION DX: post
caniectomy
 PROBLEM SCIENTIFIC GOALS/ OBJECTIVES NURSING RATIONALE EVALUATION
BASIS CRITERIA INTERVENTION
August 27, After 5 hours of Monitor VS and Serves as baseline August 27, 2010 @
2010 @ Body defenses if nursing intervention, record. data 2:00 pm
09:00 am compromised patient will be free from Goal met.
leads to an Bed side care. To promote comfort. Patient was free from
infection and understand
S/O> With increased risk for infection and had
stapled infection that may the Observe signs of To determine understood the risk
wound on left result from risk factors of infection. infection such as presence, character factors of infection as
temporoparie pathogens Outcome Criteria: inflammation. and severity of recent evidenced by:
tal area invading the body condition.
> dressing system that will a.) absence of signs of a.) absence of signs of
soaked with disrupt infection such as Instruct to maintain To prevent acquiring infection such as
blood noted homeostasis, redness of site, swelling, proper hygiene. infection from
redness of site,
> Disruption giving way to unsanitary
pus, foul odorous swelling, pus, foul
of skin infections arising Demonstrate proper environment.
surface locally and discharges, afebrile hand washing. odorous discharges,
noted eventually, Hand washing is the afebrile
systemically. b.) Verbalizing Instruct client to universal precaution.
understanding of maintain surgical b.) Verbalized
REFERENCE: individual causative/ risk site clean and dry. Moisture environment understanding of
A> Risk for http://www.scribd factors of infection is suitable for individual causative/
Infection R/T .com/doc/167791 Encourage to have bacterial growth.
risk
stapled 27/Nursing-Care- adequate intake of
c.) Identify interventions factors of infection
wounds on Plan nutritious food esp. Food rich in protein
left to rich in vit. C and promotes wound
temporoparie prevent or reduce risk protein. healing. Food rich in c.) Identified
tal area for developing an vit. C boosts immune interventions to
infection system to fight prevent or reduce risk
infection. for developing an
infection