Vous êtes sur la page 1sur 8

Nursing Care Plan Assessment Subjective: Objective: -presence of incison -hemoglobin count of: V/S: Diagnosis Risk for

r infection related to impaired primary and secondary defence(decrease haemoglobin level) Planning Long term: After 3 days of nursing intervention the client will be able to achieve improved condition from risk factor. Short term: After 15 minutes of nursing interventions the client verbalizes understanding of risk factor. After 20-30 minutes of nursing intervention the client will collaboratively identify interventions to reduce risk of infection After 20-30 Intervention Observe for localized signs of infections at insertion sites of invasive lines, sutures, surgical incisions and wounds Rationale Impaired secondary defences can make the person at stake for infection especially when the first line of defences was also altered. (Microbiology: a human perspective; page 387-388) To prevent invasion of microorganisms on the wound site. (Fundamentals of Nursing: page 881) Evaluation Long term: After 3 days of nursing intervention the client has been able to achieve improved condition from risk factor.

Emphasize importance of hygienic practices especially on areas where the suture is located.

Short Term: After 15 minutes of nursing intervention the client verbalized understanding of risk factor.

Review individual nutritional needs and need for rest with caution against post partum conditions.

After 20-30 minutes of nursing For the body to cope up with the intervention the nutritional deficiency which leads client collaboratively to the impairment of the identify secondary defences. Foods, interventions to vitamins and herbs may prove reduce risk of helpful for increasing hemoglobin infection levels. However, low hemoglobin count may be due to underlying After 20-30 minutes medical conditions and so, it is of health teaching necessary to rule out the the client has been possibility of such diseases and able to demonstrate

minutes of health teaching the client will be able to demonstrate techniques and lifestyle changes to promote safe environment.

disorders. If the condition is caused by blood loss due to bleeding ulcers, it is the ulcer that needs treatment, along with measures to increase hemoglobin count. In case of severe anemia, blood transfusion is also suggested, for a quick replacement of iron and hemoglobin. In short, decrease in hemoglobin count may be due to different reasons. If it is due to low intake of iron, then, iron supplements or a diet that is rich in this mineral will do. If there is any underlying medical condition that is causing the dip in hemoglobin, that condition has to be treated, so as to increase the hemoglobin levels.( http://www.buzzle.com/ articles/ how-to-increase-hemoglobinlevels.html)

techniques and lifestyle changes to promote safe environment.

To monitor one of the causative factor for the risk condition.( http://www.orsense.com/?id=808) Monitor

Hermoglobin count and perform blood transfusion as ordered

Assessment Subjective: Medyo nahihirapan akong huminga saka, nararamdaman ko rin na mabilis akong mapagod at nanghihina minsan Objective: >pale skin,palpebral conjunctiva and nailbed. >tachypnea >RR: 28cpm

Diagnosis Ineffective breathing pattern related to decrease haemoglobin count as manifested by fast breathing with rate of 28 cpm

Planning Long term: After 3-4 weeks of Nursing Intervention the client will be able to demonstrate improved ventilation and adequate oxygenation of tissues by arterial blood gas sampling within clients normal limits and absence of symptoms of respiratory distress. Short term: After 15-30 minutes of nursing intervention the client will verbalize awareness of causative factors

Intervention Discuss the etiology of the identified related factor to the client.

Rationale To gain cooperation throughout the intervention. (NANDA: page 115)

Evaluation Long term: After 3-4 weeks of Nursing Intervention the client has been able to demonstrate improved ventilation and adequate oxygenation of tissues by arterial blood gas sampling within clients normal limits and absence of symptoms of respiratory distress. Short term: After 15-30 minutes of nursing intervention the client verbalized awareness of causative factors After 15-30 minutes of Nursing intervention the client initiates needed lifestyle changes including nutritional changes.

Elevate head of bed or have client sit up in chair, as appropriate.

To promote physiological and psychological ease of maximal inspiration.(NANDA: page 115)

Review individual nutritional needs and need for rest with caution against post partum conditions.

For the body to cope up with the nutritional deficiency which leads to decrease haemoglobin level in the blood. Foods, vitamins and herbs may prove helpful for increasing hemoglobin levels. However, low hemoglobin count may be due to underlying medical conditions and so, it is necessary to rule out the possibility of such diseases and disorders. If the condition is caused by blood loss due to bleeding ulcers, it is the ulcer that needs treatment, along with measures to increase hemoglobin count. In case of severe anemia, blood transfusion is also suggested, for a quick replacement of iron and hemoglobin. In short, decrease in hemoglobin count may be due to

After 15-30 minutes of Nursing intervention the client will initiate needed lifestyle changes including nutritional changes. After 15-30 minutes of Nursing intervention the client will demonstrate appropriate coping behaviour.

different reasons. If it is due to low intake of iron, then, iron supplements or a diet that is rich in this mineral will do. If there is any underlying medical condition that is causing the dip in hemoglobin, that condition has to be treated, so as to increase the hemoglobin levels.( http://www.buzzle.com/ articles/ how-to-increase-hemoglobinlevels.html)

After 15-30 minutes of Nursing intervention the client demonstrated appropriate coping behaviour.

Monitor Hermoglobin count and perform blood transfusion as ordered

To monitor one of the causative factor of the present condition.( http://www.orsense.com/?id=808)

ASSESSMENT Subjective cues : Medyo sumasakit ang paligid ng tahi ko. Objective cues: >Surgical incision >Grimace >3 pain scale >swelling around site

DIAGNOSIS Impaired tissue integrity related to surgery

PLANNING Within 8 hours of nursing Intervention the client will be able to have timely wound healing/repair by: a.demonstrating understanding and importance of self care activities; b. developing realistic and positive attitude towards the situation; c. identifying possible danger signs of the wound and refer for any unusualities noted, such as pain, etc.; d. not exhibiting any other complications (e.g infection, edema, redness, etc) and unsual in the vital signs;

INTERVENTION 1.) Reassess the characteristics of the wound, including color, size, drainage, and odor.

RATIONALE these data provide information on the extent of damage. Color of tissue is an indication of tissue viability and oxygenation. Odor may arise from infection present in the wound; it may also arise from necrotic tissue. Wound drainage or exudates is a normal part of wound physiology and must be differentiated from pus, which is an indication of infection. Purulent drainage from the injured area is an indication of infection. .(Fundamentals of nursing:856-..) frequent assessment can detect signs and symptoms of possible infection, complications. .(Fundamentals of nursing:856-..)

EVALUATION After 8 hours of nursing Intervention the client has been able to have timely wound healing/repair by. a.demonstrating understanding and importance of self care activities; b. developing realistic and positive attitude towards the situation; c. identifying possible danger signs of the wound and refer for any unusualities noted, such as pain, etc.; d. not exhibiting any other complications (e.g infection, edema, redness, etc) and unsual in the vital signs;

2.) Inspect the incision every shift using the REEDA (redness, edema, ecchymosis, discharge and approximation) method

3.)Identify signs of itching and scratching.

4.)Instruct and assist the patient with general hygiene, including hand washing and toilet practices.

the patient who scratches the skin in attempt to relieve intense itching may open skin lesions and increase risk for infection.(Fundamentals of nursing:856-..)

proper hand washing is the most effective method of disease prevention. Bacteria from hands can easily contaminate other areas.(Fundamentals of nursing:856-..)