ACTUAL NURSING CARE PLAN ASSESSMENT S>”Medyo agnerbios ak nga maoperaan” O> vital signs taken as follows: -BP=140/80mmHg

-RR=20cpm -PR=61bpm -T=36.5oC > non-conversant but cooperative > Able to do ADL as to bed mobility, feeding. >on NPO diet >not in respiratory distress EXPLANATION OF THE PROBLEM Renal function Test are advanced OBJECTIVES STO: Within 3 hours of nursing interventions, the patient will be able to identify ways to deal with and express anxiety. NURSING INTERVENTIONS Dx: > Monitored vital signs and record accordingly. >Assessed respiratory status. Tx: >Established rapport. > Assisted patient on comfortable position. >acknowledged patient’s verbalization of anxiety. >IVF regulated and checked for patency. > Anticipated and attended to needs Edx: > Encouraged on the following: mild anxiety to scheduled surgical operation - to verbalize feelings and discomfort to take rest and sleep > to know appropriate nursing interventions to be done. > provide comfort to the body causing relief of anxiety > for patient to address and reduced feelings of anxiety RATIONALE EVALUATION STO: After 3 hours of nursing intervention, the patient was able to identify ways to deal with and express anxiety like conversing with SO’s and reading newspaper.

> Serve as a baseline data > To know if the patient is in respiratory distress. > To gain trust and cooperation. > Helps to alleviate feeling of anxiety. > to assure that anxiety is a normal feeling. > to avoid circulatory overload. > For patient not to strain self.

indicating advanced BPH (Benign Prostatic Hyperplasia) urinary obstruction

urgency, frequency, hesitancy, decreased urine stream, and dribbling

LTO: Within 8 hours of nursing interventions, the patient will be able to appear relaxed and report anxiety is reduced to a manageable level.

LTO: After 8 hours of nursing interventions, the patient was able to appear relaxed and report anxiety is reduced to a manageable level.

Nursing diagnosis: Mild anxiety related to upcoming surgical operation. (Prostatectomy)

surgical operation (prostatectomy) is indicated to prevent BPH

- to have diversional activities like reading

newspaper and conversing with SO”s > Emphasized the importance of therapeutic regimen. > Emphasized the presence of Significant others > Informed on NPO Diet. > For patient to comply with the pharmacological interventions. > Help alleviate the anxiety of the patient >for patient to understand the reasons for NPO preoperatively

POTENTIAL NURSING CARE PLAN ASSESSMENT O>febrile, 38.5 >swelling surgical incision >redness noted on the surgical wound > wet surgical dressing > weakness in appearance >irritable >restless Nursing diagnosis: Risk for infection related to traumatized tissue secondary to post prostatectomy. EXPLANATION OF THE PROBLEM Prostatectomy Surgical incision Tissue trauma OBJECTIVES STO: Within 8hours of nursing interventions, the patient will be able to identify proper actions to prevent possible occurrence of infection and verbalize understandings of individual causative or risk factors of infection. LTO: After 2 days of nursing interventions, the patient will achieve timely wound healing, be afebrile, and identify interventions to prevent or reduce infection. NURSING INTERVENTIONS Dx: > Monitor vital signs. RATIONALE EVALUATION STO: After 8hours of nursing intervention, the patient will be able to identify proper actions to prevent infection and verbalize understandings of individual causative risk factors of infection.

> observe for localized Signs of infection at insertion sites and at wound site > assess surgical incision Tx: >Establish rapport. > Assist patient on comfortable position. > maintain sterile technique in changing wound dressing >perform TSB > Acknowledge patients question regarding infection cause and control >Give due antibiotics

> vital signs are important baseline data because it proves possible infection > to assess causative and contributing factors of infection > to note presence of infection and wound complications > To gain trust and cooperation. > for patient not to strain self. > to reduce or correct existing infection risk factors. > to address fever > gives knowledge and background to patient regarding the cause and effects of infection > Helps prevent infection.

Opening of tissue

Possible Site of entry of pathogens causing infection

Risk for infection

LTO: After 2 days of nursing interventions, patient will be able to achieve timely wound healing, be afebrile and identify interventions to prevent or reduce infection such as proper cleaning of wound aseptically.

Edx: > Encourage on the following: - to increase fluid intake.

> Keep fluid and electrolyte balance of the body

- to take rest and sleep > helps the patient’s body to regain strength >emphasize necessity of taking antibiotics > for patient to cooperate in taking meds for infection control and prevention > instruct patient and significant others on proper prevention of infection > to promote wellness and prevent infection

ACTUAL AND POTENTIAL NCP

Patient’s case: PROSTATECTOMY

Submitted to: Mr. Alimbuyao, Jeffrey Submitted by: Buangan, Jervise July 3, 2008

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