5-NCP_APIE

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B. PLANNING

Nursing Care Plans POSTOPERATIVE February 23-25, 2010

ANALYSIS PLANNING INTERVENTION EXPECTED OUTCOME

Subjective:

masakit ang binti ko

Pain scale of 7/10

Objective:

Grimace

Increased perspiration Guarding behavior at the

site of tissue damage (right

thigh)

Diagnosis:

Acute pain r/t tissue damage

Scientific Explanation:

Due to surgical procedure, the tissue

has been damage that stimulates therelease of pain receptors at the site

such as prostaglandin, serotonin and

bradykinin.

Within 30minutes to 1 hour of

rendering proper nursing

interventions the clients pain will be

alleviated f rom a scale of 7/10 to

2/10.

Independent:

Assess level of pain,

determining the intensity at its

best or worst.

(Systematic ongoing assessment

and documentation provide

direction for the paintreatment.)

Teach relaxation technique such

as deep breathing exercise,

pursed lip breathing and muscle

relaxation.

(A relaxation technique reduces

tension and anxiety which

potentiates the perception of

pain). Provide distractions like

conversation.

(Destruction helps increase

relaxation and ability to cope

with discomforts.)

Divert client into activities like

reading newspapers.

(To divert feelings of pain)

Dependent/Collaborative:

Administered analgesics as

prescribed.

(Analgesics has pharmacological

action that decreases pain)

After 30minutes to 1 hour of

rendering proper nursing

interventions the clients pain will be

alleviated f rom a scale of 7/10 to

2/10.

As evidence by: Loss of guarding behavior

No grimace

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Subjective:

Ø

Objective:

w/ incision in the right thigh

w/ open wound at the right

buttocks

presence of pressure ulcer

at the back

presence of internal fixator

at the right thigh

Diagnosis:

Impaired skin integrity r/t mechanical

factors (accident, surgical procedure

and pressure)


Due to accident happened to thepatient he has developed

osteomyelitis that requires surgical

debridement that results to an

incision of the right thigh, due also to

his condition that requires bed rest

he has developed pressure ulcer at

the back.

Within 3 hours of rendering proper

nur

sing inter

vention the client will beable to demonstrate and state

measures in improving the impaired

site.

Independent:

Assess the site of skinimpairment and determine

the cause.

(This will provide basis for

the appropriate

management of the

condition)

Maintain the head of the

bed at the lowest degree

possible or use lift devices,pillows and foam wedges.

(To prevent pressure at the

site)

Encourage the client not to

position his self at the

impaired site.

(To protect against adverse

effect of external mechanical

forcers such as pressure and friction)

Advice the patient to

monitor site of impaired skin

at least once daily for color

changes, redness, swelling,

warmth, pain.

(Systemic inspection can

identify impending problem

early) Move the client f rom side to

side at least every 2-3 hours.

(For management of

pressure ulcer to minimize

the pressure at the site and

provide air)

Tell the client to avoid

massaging around the site.

After 2 hours of rendering proper

nur

sing inter

vention the client will beable to demonstrate and state

measures in improving the impaired

site.

As evidenced by:

Verbalized understanding of

the interventions given

Able to state different

measures to protect andheal the skin.

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(Massage may lead to deep

tissue trauma)

Educate the client

r

egar

dingproper wound care and

dressing.

(To be knowledgeable

enough and independent

when have been discharged)

Educate the client to be

cautious enough when

voiding or eliminating.

(To prevent direct contact tobody secretions that may

increase the possibility of

infection)

Advice the client to increase

Vitamin C and protein

intake.

(To help in strengthening of

immune system and healing

of wound)


Irrigation of wound

aseptically.

(To prevent development or

growth of microorganisms at

the site)

Administer antibiotics as

prescribed such asgentamicin.

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Subjective:

nahihirapan akong tumayo at

gumalaw ng maayos

Objective:

Limited ability to perform

gross motor skills such as

walking and sitting alone

Limited ROM

Difficulty in turning position

f rom side to side Remarkable gait changes

(decreased walking speed

and difficulty intiating gait)

Presence of an internal

fixator at the right thigh

Use of crutches and wheel

chairs

Diagnosis:Impaired physical mobility r/t loss of

integrity of bone structures


Due to the presence of internal

fixator and surgical procedure that

was done recently (debridement) the

patient still cannot manage to move

well as a result of bone invasion.

Within 2 to 4 hours of rendering

proper nursing intervention the client

together with the significant others

will be able to demonstrate different

measures to increase physical

mobility of the client.

Independent:

Screen for mobility skills in

the following order: (1) bed

mobility; (2) supported and

unsupported sitting; (3)

transition movements such

as sit to stand, sitting down

and transfers, and (4)

standing and walking

activities.

(Abilities of the client shouldbe assessed to determine

how best to facilitate

movement and protect the

nurse f rom harm)

Determine the cause of

impaired mobility.

(To provide the nurse with

enough data)

Monitor and record clientsability to tolerate activity

and use of all four

extremities, note PR, RR, BP,

and skin color before and

after the activity.

(To evaluate clients

capability and response)

Demonstrate and perform

passive ROM exercises withthe patient together with

the significant others.

(These exercises help

reverse weakening and

atrophy of muscles)

Assist client in changing

position such as f rom lying

to sitting, sitting to standing

After 2 to 4 hours of rendering

proper nursing intervention the client

together with the significant others

will be able to demonstrate different

measures to increase physical

mobility of the client.

As evidenced by:

Verbalize willingness in

doing the said activities

Demonstrate use of adaptive devices (wheelchair

and crutches) to increase

mobility

Demonstrate the different

ROM exercises correctly

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etc. for every 2 hours.

(Turning and shifting weight

increase circulation and help

prevent skin breakdown)

Encourage ambulation and

provide assistance as

necessary.

(Ambulation maintains, and

improve circulation, and also

helps prevent muscle

atrophy and maintains

bowel function) Use a gait walking

belt/wheelchair when

ambulating client.

(To prevent/reduce

incidence of injuries)

Increase clients

independence to perform

ADLs and discouraged

helplessness when he getsstronger.

(Providing necessary

assistance may promote

dependence and loss of

mobility)


Obtain any assistive devices

needed for activity such asgait belt, walker, crutches

and wheelchair before

activity begins.

(Activity devices can help

increase mobility and to

have a balance)

Consult with Physical

Therapist for further

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evaluation, strength

training, gait training, and

development of mobility

plan.

(trainings such as gait

training etc., can help to

improve balance and

coordination)

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Subjective:

nag-aalala ako baka hindi na bumalik

sa dati ang paa ko

Objective:

Poor eye contact

Increased perspiration

Irritable

Weak in appearance

Presence of internal fixator

at theright thigh

Diagnosis:

Anxiety r/t change in health status


Client experiences anxiety due to

previous surgery, his health status

was changed and hes not sure of

what will happen to him when he willbe discharged.

Within 2-3 hours of rendering proper

nursing interventions the clients

level of anxiety will be minimized.

Independent:

Assess the clients level of

anxiety and physical

reactions to anxiety.

(Anxiety is known to

extensify physical

symptoms)

Provide a quiet environment

with diversion.

(Excessive noise increases

anxiety, involvement in aquiet activity can be

soothing for the patient)

Use empathy to encourage

the client to interpret the

anxiety symptoms as

normal.

(This will facilitate

therapeutic communication

to fatherly assess clientsfeelings)

Teach client regarding deep

breathing exercises.

(Deep breathing exercise

can help the client to be

calm and relaxed)

Encourage the client to use

positive self talk such as

gagaling din ako, kaya koto.

(Changing negative

statements to positive

statements in some way

may help to decrease

anxiety)

Provide backrubs or

massage for the client to

After 2-3 hours of rendering proper

nursing interventions the clients

level of anxiety will be minimize.

As evidenced by:

Verbalize decrease in

subjective distress

Able to establish eye contact

Minimize sweating

Demonstrate ability to

reassu

re self

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decrease anxiety.

(Massage significantly

decrease the anxiety or

perception of tension)

Use therapeutic touch and

healing touch techniques.

(Anxiety was significantly

reduced in therapeutic

touch placebo condition,

healing touch is one of the

interventions readily

available toreduce anxiety)

Use guided imagery to

decrease anxiety.

(Anxiety was decreased with

the use of guided imagery

for post-op pain)

Explain all the activities,

procedures and issues that

involved the client. Use non

medical terms, and calm andslow speech.

(To increase coping skills

because they know what to

expect)

Explore coping skills

previously to relieve anxiety.

(methods of coping with

anxiety that has been

successful in the past arelikely to be helpful again)

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Subjective:

Ø

Objective:

w/ incision in the right thigh

presence of internal fixator

at the right thigh

limited body movement

Diagnosis:

Risk for infection r/t tissue

destr

uction and incr

easedenvironmental exposure


There is still a risk for infection due to

damage tissue as a result of

debridement and unsanitary

exposure to hospital environment,

microorganisms can easily enter thesite.

Within 2-4 hours of rendering proper

nursing intervention the client will be

able to remain f ree f rom signs and

symptoms of infection.

Independent:

Assess skin for color, texture

moisture and turgor

(Intact skin is natures first

line of defense against

microorganisms entering the

body)

Monitor the clients vital

signs specifically body

temperature.

(Change in vital signs such asin temperature may signify

presence of infection)

Use appropriate hand

hygiene when attending to

patient or when doing

procedures.

(To reduce/ prevent

transmission of

microorganisms) Ensure sterility of

materials/supplies when

performing procedures such

as wound care/dressing.

(To prevent contamination)

Ensure the clients hygienic

care with hand washing,

bathing, and oral care.

(Hygienic measure isimportant to minimize/wash

out certain microorganism in

the clients body that may

cause infection)

Encourage the client to

increase fluid intake.

(Fluid intake facilitates

elimination that may

After 2-4 hours of rendering proper

nursing intervention the client will be

able to remain f ree f rom signs and

symptoms of infection.

As evidenced by:

Vital signs w/in normal

range:

BP: 110/80

PR:85

RR: 20T: 36.1C

Site remains f ree f rom any

signs of infection such as

swelling.

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decrease the possibility of

having infection)

Encourage a balance diet,

emphasizing proteins, fatty

acids and vitamins (C, B12,

E)

(To boost immune system

and strengthens the body)


Administered antibiotics as

pr

escr

ibed. (To prevent infection)

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