Nursing Care Plan

Name of the Patient : Raul Isidro Age: 24 y/o, male, single Address: Pili Cam. Sur Medical Diagnosis : Hacked wound medial aspect m/3rd forearm; traumatic amputation little finger, left Assessment SUBJECTIVE: Medyo okay naman ang lugad ko, expose lng kaya ini sa kamot. , as verbalized by the patient. OBJECTIVE: Open wound Soaked dressing on the left forearm (-) antibiotic medications Temp: 36.9 Pale conjunctiva Normal capillary refill of 2 sec. Redness around the affected area Mild swelling is evident on right hand Diagnosis Risk for infection r/t decreased skin integrity as manifested by open wound Planning Short-Term Goal : Within the shift, patient will be able to identify ways to reduce risk for infection. Will gain knowledge of infection control as evidence by discussing the wound care. Long-Term Goal: At the end of hospitalization, patient will not manifest any signs and symptoms of infection. Nursing Intervention Independent: monitor vital signs Rationale Evaluation Goal met:

this would
determine if there has been systemic infection occurring inside the body To gain trust and cooperation of the pt. Fever may indicate infection.

Establish rapport. Assess signs and symptoms of infection especially temperature. Teach the patient to wash hands often esp. after toileting and before and after meals Emphasize the importance of hand washing technique. Discuss to the patient the signs of infection(redness, swelling, pain, purulent drainage and fever) Maintain aseptic technique when changing dressing/caring wound. Keep area around wound clean and

Patient has gained knowledge in infection control as evidence by discussing the wound care. Patient was free from any signs and symptoms of infections as manifested by absence of fever.

Hand washing
reduces possible infections. It serves as a first line of defense against infection. To impart the patient when the wound become infected and when to sought medical care. Regular wound dressing promotes fast healing and drying of wounds.

Wet area can be

dry. Advise to increase vit. C, protein and iron in the diet Dependent: Emphasize necessity of taking antibiotics as ordered and advice to secure medications as prescribed.

lodge area of bacteria. It promotes wound healing. Premature discontinuation of treatment when client begins to feel well may result in return of infection. Goal met. The patient was able to improve as evidenced by demonstrating ability to take medication given appropriately and ability to cope with incompletely relieved pain. LTG: The patient was able to demonstrate no signs of pain as evidenced by verbalization of mild or no report of pain.

Acute Pain Related to inflammation and edema

Short-term goal: After 1 hour of rendering care, patients condition will improve as evidenced by demonstrating ability to take medication given appropriately and ability to cope with incompletely relieved pain Long-term goal: After 2 days of rendering care, patient will demonstrate no signs of pain as evidenced by verbalization of mild or no report of pain.

SUBJECTIVE: Medyo makulog ang kamot ko, dai ko nga maghiro ta garu gatok. As verbalized by the patient. OBJECTIVE: acute pain on the right hand. Redness and swelling on the right hand. Pale in appearance Limited range of motion on affected area. Protective measures noted. (-) analgesic

INDEPENDENT: Perform a comprehensive assessment of pain including location, characteristics, onset, duration, frequency, quality, intensity or severity and precipitating factors of pain Assess for signs and symptoms of pain. Assess patients willingness or ability to explore a range of techniques aimed at controlling pain Reduce or eliminate factors that precipitate or increase pain. experience. Teach the use of non pharmacologic techniques.

Pain is a subjective experience and must be described by the client in order to plan effective treatment.

To allow prompt intervention and improved pain control Some patients will feel uncomfortable exploring alternative methods of pain relief. To enhance overall management of pain Use of noninvasive pain relief measures can increase the release of endorphins

medications.

Promote relaxation through bed rest, music therapy, etc.

Provide rest periods to facilitate comfort, sleep, and relaxation

and enhance the therapeutic effects of pain relief medications To decrease pain perception and increase effectiveness of pain management measures. The patients experiences of pain may become exaggerated as the result of fatigue. In a cyclic fashion, pain may result in fatigue, which may result in exaggerated pain and exhaustion.

Sleep deprivation related to uncomfortabl e environment SUBJECTIVE: Dai ako makaturog tultol ta maribok saka mainit. OBJECTIVE: (+) irritation (+) lack of energy Yawning upon interview

Short-term goal: After nursing interventions, the client will be able to: Be assessed with The causative/ contributing factors of his sleep deprivation. Know the importance of enough sleep in our body. Understand proper sleep

DEPENDENT: Administer analgesic if positive as ordered.

To relieve pain.

>Determine the clients usual sleep pattern. >Determine the clients expectations of adequate sleep. >Identify circumstances that interrupt sleep. >Recommend/ request activities in the evening.

>Provides comparative baseline. >Provides opportunity to Address misconceptions/ Unrealistic expectations. >To reduce stimulation so client can elax. >To decrease tension, prepare for rest/sleep.

Goal met. The client was able to report improvement in sleep pattern as manifested by: Making an optimal sleep schedule Having 6 to 8 hours of continuous sleep Feeling

Dizziness noted Eyebags present

inducing technique. Long-term goal: After 8 hours of Nursing intervention, the client will be able to report improvement in sleep pattern.

>Instruct patient to do relaxation techniques >Provide calm and quiet Environment.

>To manage controllable sleep disrupting factors. > For conducive sleep environment.

refreshed upon waking up.

Prepared by: CALLO, JOY C. BSN 4 A- NCF