VII.

Nursing Care Plans

Assessment Subjective: nars panu ko lilinisin ng maayos ang ari ko

Diagnosis Risk for infection related to insufficient knowledge to avoid exposure to pathogens

Planning After 8 hours of nursing intervention, the patient verbalize understanding of risk factors

Intervention -teach risk factors for occurrence of infection (ex. skin integrity, environmental exposure) -Proper hand washing -cleanse incision sites daily

Rationale -to have proper knowledge about risk factors in infection -to avoid cross contamination -to prevent build up of pathogens

Evaluation After 8 hours of nursing intervention, the patient has verbalized understanding of risk factors

Assessment Subjective:Su masakit sakit ung inoperahan sakin as verbalized by the patient Objective: -Grimace facial reaction -pain scale of 6

Diagnosis Pain related to surgical incision

Planning After 8 hours of nursing intervention, the patient will show decrease or relief of pain.

Intervention -monitor vital signs, including pain scale

-provide adequate rest periods and assist in a comfortable position -encourage deep breathing exercises -administer analgesics as ordered Diagnosis Safe care Planning After 8 hours of Intervention - identify degree of

Rationale -establish baseline in order to determine needed interventions -promotes recovery - relieves muscle and emotional tension - to relieve pain Rationale -to identify the

Evaluation After 8 hours of nursing intervention, the patient has shown relief of pain.

Assessment Subjective:

Evaluation After 8 hours of

 nahihirapan deficit: hygiene nursing individual impairment extent of the akong linisan related to pain, intervention, the patients ang ari ko discomfort Planning patient will be -allow patient to Evaluation strength Assessment Diagnosis Intervention Rationale able to perform perform activities to -to make the the fullest of his patient Subjective: Fluid After 8safe care -monitor I/O -accurately The goal was met activities within ability and assist as independent of madalas volume hours of -instruct to measuring level of own needed their own skills ako Deficit Nursing increase oral intake and ability and assist if matuyuan ng related to Intervention fluid intake output is needed. lalamunan dehydration s, the -advice to -provide vitalpositive for the -for ngayon at as patient will avoid client withfor reinforcement encouragemen tasks successfully t of the patient tuyo lagi ang manifested show caffeine, tea, fluid volume independently to participate bibig ko by diarrhea improved grape and and/or overload accomplished in the hydration fruit juice activities Objective: -to add status (diuretics) -Decrease more urine output -advice to electrolyte -Thirst take fluids to the body (drinking that replaces eagerly) needed -Dry lips and electrolytes skin (ex. -Poor skin Gatorade) turgor

nursing intervention, the patient is able to perform safe care activities