Actual Nursing Care Plan 2

ACTUAL NURSING CARE PLAN #1
ASSESSMENT
NURSING
DIAGNOSIS
OBJECTIVES
IDEAL
INTERVENTION
ACTUAL
INTERVENTION
RATIONALE
EVALUATION
Subjective cues:
“dugay2x naman
ni akong samad
ma’am , ga.katol
sya sa kilid, dli pd
sya sakit kani lang
sa gahi kung
e.duot. Naa sa
3/10 ma’am,
makaya-kaya ra
man.” As
verbalized.

Objective cues:
 Disruption
of skin
surface at
the R upper
arm
 Dry open
wound @
7cm in
diameter
 Localized
erythema
surrounding
Impaired skin
integrity related
to inflammatory
response
secondary to
infection
Short Term:
At the end of 8
hours of nursing
care, patient will be
able to:
 Verbalize
understanding
of skin care
regimen
 Verbalize relief
of discomfort
 Verbalize
understanding
of the
importance of
caring the
infected wound
 Participate in
prevention
measures and
treatment
program

Long Term:
Independent:

Independent:
1. Examined the skin
for open wounds,
discoloration.
Described and
measured wound
and observed
changes.





2. Educated patient
proper skin hygiene
such as washing
thoroughly and pat
dry carefully.





3. Inspected the wound
every shift using
FREEDA (redness,
edema, ecchymosis,

1. Provides information
regarding skin
circulation and
problems that caused
by application of
dressing.
Establishes
comparative
baseline providing
opportunity for
timely intervention.

2. Maintaining clean,
dry skin provides a
barrier to infection.
Patting skin dry
instead of rubbing
reduces risk of
dermal trauma to
fragile skin.

3. Frequent assessment
can detect early signs
and symptoms of
further infection.
Short Term:
At the end of 2-4
hours of nursing
care, patient has
been able to:
 Demonstrate
ways and
technique on
how to reduce
pain to a
tolerable level.
 Follow
prescribed
pharmacologic
al regimen.
 Verbalize
understanding
of pain
management

Long Term:
At the end of 24
the wound
 Edematous
surrounding
areas
 Localized
heat
 Pustule
noted with
small
amount of
reddish
discharges
surrounding
the areas
 With some
purulent
discharges
 (+) pruritus
on the
surrounding
of the
wound

At the end of 25
hours of nursing
care, patient will be
able to:
 Exhibit no
further skin
breakdown
 Maintain
wound intact
 Minimize
redness on the
surrounding
area
 Display
improvement
on wound as
evidenced by
absence of
some purulent
discharges,
absence of
itchiness

discharge and
approximation).

4. Emphasized the
importance of
adequate nutrition
and fluid intake.


5. Provided and
applied wound care
and dressing
carefully.

6. Encouraged
adequate hydration
and nutrition.


7. Educate patient on
the importance of
keeping the skin
clean and dry.

8. Kept area clean and
dry, support incision
(splinting when
couching).

9. Repositioned patient
on regular schedule,
involving patient in


4. Improved nutrition
and hydration will
improve skin
condition.
5.


6. Adequate hydration
and nutrition helps
maintain skin turgor
and suppleness.

7. Moisture softens the
skin and causes a
break in the skin
integrity.

8. To assist body’s
natural process of
repair.


9. To enhances
understanding and
cooperation.


hours of nursing
care, patient will be
able to:
 Know and
perform
activities that
do not only
provide relief
from pain but
helpful in
dealing the
disease
condition.

Has not been able
to:
 Verbalize
relief of pain
from a scale of
8/10 to 3-5/10


reasons for and
decisions about
times and positions.

10. Encouraged and
assisted early
ambulation or
mobilization.




Collaborative:
1. Administered
antibiotic, as
indicated.
 Cefuroxime
750mg 1
vial
Q12˚


2. Administered
replacement of
fluids and
electrolytes.


10. Promotes
circulation and
reduces risks
associated with
mobility.





1. To facilitate
prophylaxis of
possible infection.
 To inhibit
synthesis of
bacterial cell
wall causing
cell death.


2. To support
circulating volume
and tissue
perfusion.



ACTUAL NURSING CARE PLAN #2
ASSESSMENT
NURSING
DIAGNOSIS
OBJECTIVES INTERVENTION RATIONALE
EVALUATION
Subjective cues:
“Init man akong
paminaw ma’am.”
As verbalized


Objective cues:
 T: 37.9˚C
/axilla
 Flushed skin
 Warm to
touch
 Good skin
turgor
appropriate
to age


Hyperthermia
related to
increased
metabolic activity
as evidenced by
elevated
temperature
Short Term:
At the end of 4 hours
of nursing care,
patient will be able
to:
 Return to normal
temperature
within normal
range


 Maintain good
skin turgor

Long Term:
At the end of 24
hours of nursing care,
patient will be able
to:
 Demonstrate
behaviors to
Independent:
1. Monitored
temperature every 2
hours.

2. Provided tepid
sponge baths.






3. Monitored vital
signs.



4. Monitored signs of
dehydration.

1. Knowing the
temperature of the
body.

2. Tepid sponge bath
may help reduce
fever. Note: use of
ice water or alcohol
may cause chills,
actually elevating
temperature.
Alcohol can also
cause skin
dehydration.

3. Effect of
temperature
increase is a change
in pulse, respiration
and blood pressure.


4. The body can lose
water through the
Short Term:
At the end of 4 hours
of nursing care,
patient has been able
to:
 Return to
normal
temperature
within normal
range, from
37.9˚C to 37.3˚C
 Maintain good
skin turgor

Long Term:
At the end of 24
hours of nursing
care, patient has been
able to:
 Demonstrate
behaviors to
monitor and
promote
normothermia






5. Evaluated skin
turgor, capillary
refill.


6. Encouraged and
instructed patient to
increase fluid intake
up to 2000mL/day.

7. Instructed to
maintain bed rest.



8. Discussed
importance of
adequate fluid

Collaborative:
1. Administered anti-
pyretic, as indicated.
 Paracetamol
500 mg 1 tab
q4˚ RTC
skin and
evaporation.

5. To determine
hydration and
circulating volume.


6. To prevent
dehydration.



7. To reduce
metabolic demands
and oxygen
consumption.

8. To prevent
dehydration.


1. To treat underlying
cause, to control
shivering.

 Antipyretics
monitor and
promote
normothermia




2. Administered
replacement of
fluids and
electrolytes.


reduce fever
by its central
action on the
hypothalamus.

2. To support
circulating volume
and tissue
perfusion.











ACTUAL NURSING CARE PLAN #3
ASSESSMENT
NURSING
DIAGNOSIS
OBJECTIVES INTERVENTION RATIONALE
EVALUATION
Subjective cues:
“sakit kayo e-ihi,
naa sa 8 ang
ka.sakit”

Objective cues:
 Pain scale =
8/10 upon
urinating
 Presence of
FBC
attached to
urobag,
draining
bloody urine
 Hematuria
 Urine output
per shift:
1000 -
1200mL

Impaired Urinary
Elimination
related to
decreased renal
perfusion,
irritation of the
kidney / ureter,
inflammation,
bladder
stimulation by a
stone secondary
nephrolithiasis

Short Term:
At the end of 4 hours
of nursing care,
patient will be able
to:
 Verbalize
understanding of
condition

Long Term:
At the end of 24
hours of nursing care,
patient will be able
to:
 Participate in
measures to
correct or
compensate for
defects
 Maintain
increase urine
Independent:
1. Noted age and
gender of the
patient.








2. Examined the pain,
noting location,
duration, intensity;
presence of bladder
spasm; or back or
flank pain.

3. Determined
patient’s usual daily
fluid intake. Noted
condition of skin
and mucous
membranes, color

1. Incontinence and
urinary tract
infection are more
prevalent in women
and older adults;
painful bladder
syndrome or
interstitial cystitis is
more common in
women.

2. To assist in
differentiating
between bladder and
kidney as cause of
dysfunction.


3. To help determine
level of hydration.




Short Term:
At the end of 4 hours
of nursing care,
patient has been able
to:
 Verbalize
understanding of
condition

Long Term:
At the end of 24
hours of nursing
care, patient has
been able to:
 Participate in
measures to
correct or
compensate for
defects
 Maintain
increase urine
output
 Reduce blood in
the urine


of urine.

4. Encouraged fluid
intake up to 3000
mL/day, within
tolerance.



5. Monitored intake
and output and
characteristics of
urine.


6. Determined
patient’s normal
voiding pattern and
noted variations.







7. Noted condition o
skin and mucous
membrane, color of


4. To help maintain
renal function, and
prevent infection;
and to increase
hydration to flushed
bacteria.

5. To provide
information about
the kidney function
and presence of
complication.

6. Calculi may cause
nerve excitability,
which causes
sensation of urgent
need to void, usually
frequency and
urgency increase as
calculus nears
ureterovesical
junction.

7. To assess level of
hydration.

output

Has not been able to
 Reduce blood in
the urine

urine.

8. Observed signs of
infection.


9. Emphasized
importance of
having good
hygiene.

10. Emphasized
importance of
adhering to
treatment regimen.


8. To help in treating
urinary alteration.


9. To promote
wellness.



10. To promote
wellness.






ACTUAL NURSING CARE PLAN #4
ASSESSMENT
NURSING
DIAGNOSIS
OBJECTIVES INTERVENTION RATIONALE
EVALUATION
Subjective cues:
(none)


Objective cues:
 Presence of
post-
operative
wound on R
lumbar area
and RLQ,
status post
nephrolithias
is
 Good skin
turgor
appropriate
to age
 Capillary
refill returns
less than 2
seconds
Impaired Skin
Integrity related
to surgical
incision, altered
body temperature
Short Term:
At the end of 8 hours
of nursing care,
patient will be able
to:
 Verbalize
understanding of
skin care
regimen
 Verbalize relief
of discomfort
 Normalize skin
turgor and
capillary refill
 Verbalize
understanding of
the importance
of caring the
incision site

Long Term:
At the end of 24
Independent:
11. Examined the skin
for open wounds,
discoloration,
blanching, and
rashes.


12. Inspected the
incision every shift
using FREEDA
(redness, edema,
ecchymosis,
discharge and
approximation).

13. Encouraged and
assisted posting of a
turning schedule,
restricting time in
one position to 2
hours or less.


11. Provides
information
regarding skin
circulation and
problems that
caused by
application of
dressing.

12. Frequent
assessment can
detect early signs
and symptoms of
infection.


13. To prevent
discomfort and
injuries to the body;
to promote
circulation.
Short Term:
At the end of 8 hours
of nursing care,
patient has been able
to:
 Verbalize
understanding
of skin care
regimen
 Verbalize relief
of discomfort
 Normalize skin
turgor and
capillary refill
 Verbalize
understanding
of the
importance of
caring the
incision site

Long Term:
At the end of 24
hours of nursing care,
patient will be able
to:
 Exhibit no
further skin
breakdown
 Maintain wound
intact
 Display no
redness on the
surrounding
area or signs of
inflammation

14. Encouraged S.O to
maintain functional
body alignment of
the patient like
positioning it
properly.


15. Encouraged
adequate hydration
and nutrition.


16. Educate patient on
the importance of
keeping the skin
clean and dry.

17. Kept area clean and
dry, support incision
(splinting when
couching).

18. Repositioned patient
on regular schedule,
involving patient in
reasons for and
decisions about
times and positions.

14. Misalignment can
lead to discomfort
and injuries to
joints, limbs or
nerves.



15. Adequate
hydration and
nutrition helps
maintain skin turgor
and suppleness.

16. Moisture softens
the skin and causes a
break in the skin
integrity.

17. To assist body’s
natural process of
repair.


18. To enhances
understanding and
cooperation.
hours of nursing
care, patient has
been able to:
 Exhibit no
further skin
breakdown
 Maintain wound
intact
 Display no
redness on the
surrounding
area or signs of
inflammation


19. Encouraged and
assisted early
ambulation or
mobilization.




Collaborative:
3. Administered
antibiotic, as
indicated.
 Cefuroxime
750mg 1 vial
Q12˚


4. Administered
replacement of
fluids and
electrolytes.




19. Promotes
circulation and
reduces risks
associated with
mobility.





3. To facilitate
prophylaxis of
possible infection.
 To inhibit
synthesis of
bacterial cell
wall causing
cell death.


4. To support
circulating volume
and tissue
perfusion.

ACTUAL NURSING CARE PLAN #5
ASSESSMENT
NURSING
DIAGNOSIS
OBJECTIVES INTERVENTION RATIONALE
EVALUATION
Subjective cues:
(none)


Objective cues:
 Presence of
post-
operative
wound on
R lumbar
area and
RLQ,
status post
nephrolithi
asis
 T: 37.9˚C
Risk for Infection
related to
inadequate
primary defenses
– break in skin or
post surgical
incision
Short Term:
At the end of 8 hours
of nursing care,
patient will be able
to:
 Verbalize
understanding of
individual
causative or risk
factor(s)
 Demonstrate
techniques,
lifestyle changes
to promote safe
environment
Independent:
1. Monitored vital
signs.



2. Assesses signs and
symptoms of
infection
especially
temperature.

3. Maintain hydration
and voiding
schedule.
1. An elevated
temperature suggests
incisional infection,
urinary tract infection
or respiratory
complications.

2. Fever may indicate
infection.





3. To prevent bladder
distention and
Short Term:
At the end of 8 hours
of nursing care,
patient has been able
to:
 Verbalize
understanding of
individual
causative or risk
factor(s)
 Demonstrate
techniques,
lifestyle changes
to promote safe
environment
 Identify
interventions to
prevent or
reduce risk of
infection
 Maintain or
normalize
temperature
within normal
range


Long Term:
At the end of 24
hours of nursing care,
patient will be able
to:
 Verbalize full
knowledge in
identifying risk
factors of
infection.
 Be free from any
signs and
symptoms
related to




4. Emphasized the
importance of
hand washing
technique.

5. Maintained
aseptic technique
when changing
dressing and/or
caring wound.

6. Kept area around
wound clean and
dry.

7. Discussed the
importance of not
taking antibiotics
unless specifically
instructed by
health care
provider.
urinary stasis which
can contribute to the
multiplication of
pathogens.

4. It serves as a first line
of defense against
infection.


5. Regular wound
dressing promotes
fast healing and
drying of wounds.


6. Wet area can be
lodge area f bacteria.


7. Inappropriate use can
lead to development
of drug-resistant
strains or secondary
infections.


 Identify
interventions to
prevent or
reduce risk of
infection
 Maintain or
normalize
temperature
within normal
range (37.3˚C)


Long Term:
At the end of 24
hours of nursing
care, patient has
been able to:
 Verbalize full
knowledge in
identifying risk
factors of
infection.
 Be free from
any signs and
symptoms
related to
infection



Collaborative:
1. Administered
antibiotic, as
indicated.
 Cefuroxime
750mg 1
vial
Q12˚

2. Administered
replacement of
fluids and
electrolytes.



\
1. To facilitate
prophylaxis of
possible infection.
 To inhibit
synthesis of
bacterial cell
wall causing
cell death.


2. To support
circulating volume
and tissue perfusion



infection