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NURSING PROCESS CARE PLAN #2

Knowledge Deficit
PATIENT'S INITIALS:_______________ STUDENT'S NAME _________________________
DATES OF CARE: _________________

ASSESSMENT ANALYSIS PLANNING IMPLEMENTATION EVALUATION

CLIENT GOALS/ SCIENTIFIC


SUPPORTIVE NURSING OUTCOME NURSING PRINCIPLES/ OBSERVATIONS/
DATA DIAGNOSIS CRITERIA ACTIONS RATIONALE CONCLUSIONS

S: Pt asked if she was Patient and family will 1.Inspect JP dressing, 1. Will act as a Pt and Mother wanted MC
allowed to shower with the Knowledge Deficit become more incision site, and Central baseline for further to take a shower. Supplies
JP drain and central line in knowledgeable regarding line and document teaching and for wrapping the site and
place. r/t the care and use of the findings. assessments. for shower were gathered.
Pt’s mom stated that she JP drain and Central 2. Will allow comfort Provided privacy.
hadn’t taken a shower in 2 Care of Jackson Pratt Drain line. 2. Provide privacy to pt. and pt will be more
days b/c they weren’t sure. And Central Line for TPN Taught family the S&S of
open to teaching.
Pt asked how to tape up the AEB infxn and skin quality.
3. Will allow pt and They verbalized that the
Site and how to tell when STG: 3. Will bring in supplies
family to site was without S&S of
the bandages needed to be 1. Patient and mother and demonstrate how to
participate and ask infxn or skin break down.
changed. will engage in wrapping wrap the JP drain,
questions about
of incision site to allow incision, and central line Showed pt where to cover
techniques.
O: __yoF pt to take a shower site. and how to dry off.
B/P 118/63 within 1 hour of request. Mother and Pt helped wrap
HR 85 2. Patient will verbalize 4. Will teach pt and the sites.
RR 20 signs of impaired skin family about S&S of 4. Will allow family
quality by eos. infxn to look out for. Daughter took shower and
Ox3 and pt to be proactive
3. Patient will report 3 dried self off.
2 days post op- JPDrain in Pt’s care and health.
placement- foul smelling S&S of infection at drain 5. Will offer self to be Post shower inspection,
serosanguineous drainage and line site by eos. present for family and pt both dressings were still
Central line placed in R to ask any questions they 5. Allows extra time dry and did not need to be
Upper Arm for TPN. LTG: have about the JP drain for pt and family to changed.
Lungs clear bil, ant/post 1. Pt will help nurses or central line care for think about extra STG met and continuing
Hypoactive BS x4 recognize when dressing them. information they need.
LTG Partially met and
Pt hair appears greasy. changes need to be made continuing.
DX: Peritonitis by discharge.
Ruptured appdx