UNIVERSITY OF TECHNOLOGY, JAMAICA

CARIBBEAN SCHOOL OF NURSING

NURSING CARE PLAN

Students name:

Jerilee Watts________ ID #: 1201465 Date: June 13th 2014

Needs: (1) Rest, Comfort and Activity (2) Safety and Security

Pt.s initials: R.P Age: 87 yrs Diagnosis: Perforated Gall Bladder

ASSESSMENT
Subjective Data:
Patient states,

inflammatory process as

My belly hurts

evidenced by facial

when I sit up.

grimaces and patients

Verbalization of
pain with a pain
scale of 7/10

Objective Data:
T= 146/96 mmHg
P= 98 b/m
RR= 20 bpm
Facial grimaces
Abdominal Pain

NURSING
DIAGNOSIS
Acute Pain related to

Limited range of
motion to back
and legs

verbalization of
abdominal pain 7/10 on
pain scale.

PATIENT OUTCOME

(3) Nutrition
INTERVENTION

RATIONALE

In 1 hour after nursing

and collaborative
interventions patient will
report pain is relieved
from a pain scale of 7/10
to 2/10.

1. Monitor and record vital signs.

2. Engage patient in diversional therapy
3. Encourage pain reduction techniques
4. Provide adequate rest
5. Administer analgesics to maintain
acceptable level of pain if not
contraindicated

1. To note deviations from normal and

evaluate efficacy of nursing
interventions rendered.
2. To relive the patients mind of the
pain.
3. To reduce pain and promote relief.
4. To promote healing
5. To decrease pain.

EVALUATION OF
CARE
After 1 hour of nursing
interventions patient
voiced that pain was
reduced form a 7/10 to
4/10 on pain scale.

ASSESSMENT
Subjective Data:

Objective Data:

NURSING
DIAGNOSIS
Impaired skin integrity

PATIENT OUTCOME
After 8 hours of nursing

1. Observe wound noting the

related to surgical

interventions the patient

presence of bleeding or

incision as evidenced by

will be able to prevent the

open wound to

further breakdown of skin

abdominal midline.

INTERVENTION

RATIONALE
1. Provide early detection of
complications

was able to prevent the

3. Reduces pressure on the

further breakdown of

skin promoting peripheral

applying prescribed

Dressing to
abdominal
midline

interventions the patient

2. to promote healing

drainage.
2. Provide wound care by

EVALUATION OF
CARE
After 8 hours of nursing

dressing keeping it dry and

circulation and reducing

sterile

risk of skin breakdown.

skin

3. Turn the patient every 2

hours

4. To encourage a faster
healing process.

4. Hydrate the patient and

encourage protein and
Vitamin C rich foods.

ASSESSMENT

NURSING DIAGNOSIS

PATIENT OUTCOME

INTERVENTION

RATIONALE

EVALUATION

Subjective Data:

Risk for infection related to

After 8 hours of nursing

invasive procedure; open

interventions patient will be

wound to abdominal midline

free from signs and

symptoms related to

Objective Data

Open wound noted to

abdominal midline

infection.

1. Monitor and record

vital signs
2. Note risk factors for
the occurrence of
infection.eg (exudate,
redness, swelling,
pain)
3. Administer antibiotics
as prescribed.
4. Ensure clean
environment
5. Change dressing
regularly
6. Wash hands before

1. To note deviations

After 8 hours of nursing

from normal and

interventions patient was free

evaluate efficacy of

from signs and symptoms

nursing interventions

related to infection.

rendered.
2. To evaluate the
presence of infection.
3. To relive the presence
of microbes to the site
of infection.
4. To reduce the
incidence of infection.
5. To prevent the
development of an
environment
conducive to bacteria.
6. To preserve sterility
and prevent infection.

and after providing

wound care.