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PROBLEM

Status
post
VP
shunting
Incision at right sub
coastal area

EXPLANATION OF
THE PROBLEM
The
patient
is
scheduled
for
VP
shunting
due
to
increased intracranial
pressure
and
diagnosis
of
destructive
hydrocephalus
measuring 2.1 x 1.7
x 1.8 cm which are
secondary
to
pituitary adenoma

S dalawa yung
sugat niya sa ulo,
linagyan daw ng tubo
para maalis yung
tubig sa loob
medyo
namamaga
nga
ata
eh
as
verbalized
by
patients significant The
patient
is
others
scheduled
for
VP
shunting wherein the
O incision site at excess
CSF
is
right subcoastal area removed to decrease
of head.
intracranial pressure.
- patient is lying on There
are
two
blanket from their incision sites done at
house
the patients head
- presence of thick (right
subcoastal
terminal hair around area).
Excess
incision sites
cerebrospinal fluid is
- inflammation at drained for palliative
right side of head
reasons.
- rubor and callor
around the wounded A break in the first
part
line of defense by the
- WBC count is below body, the skin, would

NURSING CARE PLAN


OBJECTIVE
NURSING
RATIONALE
INTERVENTION
LTO : after 3 days of Dx :
Dx :
Nursing Intervention
1.
monitor
vital 1. this
would
the client will be able
signs
determine
if
to prevent the risk
there has been
for infection
systemic
infection
STO :
occurring inside
After 8 hours of
the body
nursing intervention,
the client with the 2.
Assess
the 2. determine
help of the significant
patients
patients
ability
others will be able
knowledge about
to
perform
to:
condition.
In
independent
1.
perform
addition,
the
interventions
independently
significant others
together with her
proper
wound
knowledge since
significant others
care
the patient may
2.
take
in
be unable to do
foods/diet
that
such because of
would
promote
neurologic
faster
wound
disturbances
healing
3.
identify
3.
assess
3. determining the
interventions that
adequacy
of
blood supply for
could prevent or
blood supply and
proper
reduce the risk
innervations
of
oxygenation
of
for infection
the
affected
the tissues which
4.
achieve timely
tissue
would aide in the
wound
healing,
progress
of
free from signs of
healing of the
infection
affected tissue

EVALUATION
Criteria
Result
After 3
days
of
Nursing
Intervention
the client was
able to prevent
the
risk
for
infection
The client with
the help of the
significant
others
was
able to:

perform
independen
tly proper
wound care

take in
foods/diet
that would
promote
faster
wound
healing

identify
intervention
s that could
prevent or
reduce the

normal at 4.2 G/L


(ref. value 5.010.0 G/L)
- patient is having
and IVF side drip of
PLNSS
500ml
+
tramadol x 24 hours

promote the entrance


of
microorganisms
which
can
cause
infection at wound
site or even sepsis
through the bodys
blood circulation if
not treated properly

5.

verbalize
feelings
of
understanding,
recovery
and
comfort

4.

A Risk for Infection


related to break in
the
skin
integrity
(right
subcoastal
area
of
head)
secondary to status
post VP shunt

5.

assess
changes
of
wound site for
depth,
width,
color,
smell,
location,
temperature,
texture,
and
discharges

obtain specific
tissue or fluid
specimen
from
the wound

4. Provides
comparative
baseline
for
future
assessment and
promote
timely
nursing
intervention and
revision of care
plan.
It
also
determines
the
risk or degree of
infection of the
wound
5. determine
is
there is infection
and
provide
information
about
nursing
interventions to
be planned and
performed
Tx :
1.

Tx :
1.
clean
the
wound every shift
or as required
using
povidone
iodine

2.

promotes
faster
wound
healing
and
prevent infection
at the wound site
prevent
accumulation

of

risk
for
infection
achieve
timely
wound
healing,
free
from
signs
of
infection
verbaliz
e
feelings
of
understandi
ng,
recovery
and
comfort

2.

3.

4.

5.

change
dressings
needed
required

exudates
and
proliferation
of
microorganisms
on the dressing,
preventing
further infection

as
or

maintain
adequate
hydration
by
proper regulation
of IVF and giving
fluids
as
indicated
provide
good
nutrition
by
giving diet rich in
protein
and
calories,
and
vitamins and/or
minerals
promote early
mobility
by
providing position
changes,
active
or
passive
exercises
and
assistive

3.

prevent
dehydration and
provide
electrolytes and
minerals needed
by the body to
recover

4.

promotes
faster
wound
healing
and
provide
the
patient adequate
source of energy
for recovery

5.

promote better
circulation
at
body parts and
prevent
excessive tissue
pressure
thus
promoting faster
wound
healing
and recovery

exercises
6.
6.

prevent
infection
determine
effectiveness
therapy
presence of
effects

and
the
of
and
side

administer and
monitor
medication
regimen
like
antibiotic
and
noting
patients
response
Ed :
1.
save
and
Ed :
restore
energy
1. encourage
for recovery
patient to have
adequate periods
of rest and sleep
2.
enable
client
and
significant
2. teach the patient
others
if
the
and
significant
client
cannot
others how to do
perform it, to do
proper
wound
proper
wound
caring
care
independently
that
would
promote
faster
wound
healing
and recovery
3.
3. teach patient and
significant others
the importance of
proper
wound

let the patient


and
significant
others appreciate
the
importance
of wound caring

care

that
would
promote
faster
wound
healing
and recovery
4.

let the patient


appreciate
the
role of proper
diet
on
his
recovery
and
allow patient to
continue
his
proper
diet
during
his
recovery

5.

let the patient


appreciate
the
importance
of
early
mobility
that
would
promote
better
circulation
at
body parts thus
promoting faster
would
healing
and recovery

6.

provide
the
nurse a plan or
revision of care
appropriate
for
the
patient
and/or
allow

4. teach patient the


importance
of
good
nutrition
during and after
recovery

5. teach patient the


importance
of
early
mobility
and exercises

6. encourage
verbalization
of
feelings
and
expectations
regarding
her

condition

nurse
to
determine needs
of patient either
spiritual,
emotional
and
physiological