NURSING CARE PLAN

Name of Patient: Age: Sex: Civil Status: Room/Bed No.:

Medical/Surgical Diagnosis: Risk for infection related to post-surgical incision

Assessment Date: Intervention Date:

CUES NURSING ANALYSIS GOAL AND INTERVENTION RATIONALE EVALUATIO

DIAGNOSIS OBJECTIVE
Subjective cues: Stem: Scientific Analysis Goal: Independent: Goal:
 “May tahi po ako Risk for infection Wounds involving To display To display
nung inoprehan injury to soft tissue progressive  Monitor  To obtain progressive
ako, di po ako Related to: can vary from minor improvement in patient’s vital baseline data improvement
maka-galaw ng Post-surgical tears to severe wound or lesion signs. and wound or lesi
maayos” as incision crushing injuries. The healing and prevent  Accepts client’s determine healing and
verbalized by the decision to suture a the risk for infection. perception of any systemic prevent the ri
patient. wound depends on pain. infection for infection.
 “kaninang umaga the nature of the (GOAL MET)
po yung surgery wound the time since  Assess the  This will
ko” as verbalized the injury was Objective: patient determine After 2-3 day
by the significant sustained the degree Long term understanding the patient’s nursing
other. of contamination After 2-3 days of regarding the ability to interventions
nursing condition. perform there will be
Objective cues: interventions, there independent significant
 VITAL SIGNS Reference: will be significant interventions progress in th
Temp.: 36.0 ⁰C Brunner & progress in the healing proce
RR: 19 cpm Suddarth’s Textbook healing process, as  Assess patient’s  To determine as evidenced
PR: 80 bpm of Medical- evidenced by: general health deviations 1) Proliferative
BP: 110/80 mmHg SurgicalNursing 11th 1) Proliferative phase condition. from normal phase
 Incision site is at Edition by Smeltzer, 2) No excessive and obtain 2) No excessiv
the right Bare, Hinkle, Cheever inflammation subjective inflammati
subcoastal area noted cues. noted
of the head
 Client is weak in  Provide  Promotes (GOAL MET)
appearance adequate rest. feeling of
 Inflammation is Short Term: rested, Short Term:
noted at the After nursing comfort and After nursing
right side of the interventions also avoid interventio
head within the 8-hour fatigue. within the
 Rubor and callor shift, the patient hour shift,
around the will be able to: patient wil
wounded area 1) perform proper  Teach client  To achieve able to:
wound care regarding proper the timely 1) perform pro
2.) verbalize wound dressing healing of wound care
understanding of the wound 2.) verbalize
the concept and and avoid understand
procedure for risk for of the conc
basic wound infection. and proced
dressing for basic
3.) identify Dependent: wound
interventions the  Administer  Each client dressing
will prevent the antibiotics as has the right 3.) identify
risk for infection ordered by the to expect interventio
4.) achieve timely physician. maximum the will
wound healing pain prevent the
relief. risk for
Medications infection
ordered PRN 4.) achieve tim
basis should wound healin
be offered to (GOAL MET)
the client at
the interval
when the
next dose is
available.