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Care Plans

Care Plans

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Published by peL
3 identified problems
3 identified problems

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Published by: peL on Jul 13, 2008
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06/05/2013

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NURSING CARE PLAN NO.1
CUESNURSINGDIAGNOSISOUTCOME CRITERIANURSING INTERVENTIONSRATIONALEEVALUATIONSubjective Cues:
Wala pako naligokay basinmabughat ko.” 
Objective Cues:
Withepisiotomywound
Has nottaken a bathRisk for infection r/ttraumatized skintissue 2º toepisiotomyShort Term Goal:Within 8º of nursinginterventions, thepatient will be ableto identifyinterventions toprevent/reduce therisk of infectionLong Term Goal:Within 3 days of nursinginterventions, thepatient will be ableto demonstratelifestyle changes topromote safeenvironment
Assess the client’svital signs
Assess for anylocalized signs andsymptoms of infection.
Stress to patient theimportance of properhand washingspecially when incontact with wound
Encourage to increasefluid intake at least 8oz per hour and eatprotein-rich foods suchas meat and beans
Encourage to takeadequate rest periods
 This will serveas a baselinedata, and willhelp us identifyanyabnormalities if one of thesesigns arealtered.
Signs andsymptomsreflect theseverity of theunderlyingcondition
Hand washingis known to be afirst line defenseagainstinfections
Increasing fluidintake andeating of foodsrich in proteinwill facilitatewound healingAfter 8º of nursinginterventions,the patient wasable to identifymeasures topreventinfection asmanifested byclient’sverbalization of:
Muinom nakogdaghan tubig,mukaon nakogmga pagkaonna taas ug protina paradali ra mayoakong samad.Manghugas koug maayo sakamot aron dilimusamot akong samad.” 
 
Emphasize thenecessity of takingantibiotics ASDIRECTEDCOLLABORATIVE:
Administer anti-infectives perprescription
 This is done toprevent fatigue
 To eradicateinfectioncausingmicroorganisms
 
NURSING CARE PLAN NO.2
CUESNURSING DIAGNOSISOUTCOME CRITERIANURSINGINTERVENTIONSRATIONALEEVALUATIONSubjective Cues:
Wala lagi konakapatotoy saakong anak kay tuasiya sa NICU.Nagsuka2x man gud to ug gihilantan.” 
Objective Cues:
Infant is not bythe mother’sside
Painful breastdue toengorgementas verbalizedby the patientInterrupted breastfeeding r/t infantillnessShort Term Goal:Within 8º of nursinginterventions, thepatient will be ableto understand theimportance of breastfeedingLong Term Goal:Within 3 days of hospital duty, thepatient will be ableto identify anddemonstratetechniques tosustain lactationuntil breast feedingis reinitiated
Assess theclient’sperceptionaboutbreastfeeding
Discuss topatient theimportance of properbreastfeeding,techniquesand thebenefits boththe motherand the babycan gain
Instructpatient toincrease fluidintake at least8 oz per hour
Encouragepatient to letthe infantfrequently
Client mayhavemisconceptionsormisinformations aboutbreastfeeding
 This is toimpart thepropertechniques of breastfeedingand will helpher applying itactually
 This willfacilitateincreaseproduction of milk
Frequentsucking of theinfant willrelieve theAfter 8º of nursinginterventions, thepatient verbalized,
Mas maayo gyud diay kung gatas sananay ang ipatotoy.Mao nalang na akobuhaton aron dilimasakit akonganak.” 

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