Saint Mary’s University

Bayombong, Nueva Vizcaya

SCHOOL OF HEALTH and NATURAL SCIENCES
NURSING DEPARTMENT

PHYSICAL NURSING CARE PLAN

Assessment Diagnosis Scientific Explanation Planning Intervention Rationale Evaluation

Subjective: Impaired  Alteration in the epidermi Short Term: Independent: Short Term:

skin s and dermis -After 4 hours the parents 1) Record the 1-3) To Goal met -
Objective: integrity will identify and explain the skin color, document After 4 hours
1. Surgical related to Due to the client·s tissue need texture and skin status and the parents
sutures in the surgical trauma on the surgical a) Keep the surgical incision turgor. provide identified and
abdomen incision incision site clean and dry. 2) Palpate skin baseline data explained the
2. Disruption b) Include vitamin C in the lesions for size for future need
of the skin From his recent surgery patient’s diet. shape, comparisons. a) Keep the
layers consistency, surgical
Caused by bowel texture, incision clean
obstruction ( Hirschsprung -After 1 day, the parents will temperature and and dry.
disease) maintain their baby’s hydration. b) Include
surgical incision clean and 3) Measure the vitamin c) In
dry. length, width and the patient’s
depth of the diet.
wound.
Long Term: 4) Support and 4) It reduces
-After 1 month the patients instruct patient in contraction of Goal met -

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 Saint Mary’s University
Bayombong, Nueva Vizcaya
SCHOOL OF HEALTH and NATURAL SCIENCES
NURSING DEPARTMENT

surgical incision will display incision support the muscles After 1 day,
a progressive improvement when at the incision the parents
in healing. turning,coughing, site thus maintained
deep breathing reducing the their baby’s
and ambulating. pain that will surgical
5) Provide be felt. incision clean
routine incisional 5) To prevent and dry.
care, keep possible
dressing dry and infection.
sterile. Long Term:
Goal met-
After 1 month
the patients
surgical
incision
displayed a
progressive
improvement
in healing.

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 Saint Mary’s University
Bayombong, Nueva Vizcaya
SCHOOL OF HEALTH and NATURAL SCIENCES
NURSING DEPARTMENT

Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation

Explanation
Subjective: Deficient The patient Short Term: Independent: Short Term:
“Ano po ang knowledge lacks cognitive -After 4 hours the 1) Assess patient’s 1) Facilitates - After 4 hours
mga dapat na of parents information relati parents will be able mother level of planning of the parents were
gawin po para related to ng to a specific to: understanding preoperative able to :
matulungan postoperativ topic. -1). Identify the teaching program, -1)Identified the
kong mapabilis e care of the signs when to call identifies content signs when to
ang paggaling pull-through Inability to make their doctor and 2) Patient teaching needs. call their doctor
ng anak ko. procedure judgments that explain why she about postoperative 2) Enhances and explained
as evidence promote or needs to report it procedures and patient’s why she needs to

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 Saint Mary’s University
Bayombong, Nueva Vizcaya
SCHOOL OF HEALTH and NATURAL SCIENCES
NURSING DEPARTMENT

Pagkatapos po by request restore health quickly: expectations, bowel understanding or report it quickly:
ano po ang for a) Bleeding/ changes, dietary control and can a) Bleeding from
mga sintomas information. secretions from the considerations, relieve stress related the incision.
na dapat na incision. activity levels/ to the unknown or b). Fever
bantayan na b) No stool in the transfers, respiratory/ unexpected. (temperature
maaaring diaper for more cardiovascular c). No stool in
maramdaman than 24 hours (1 exercises; anticipated colostomy bag or
ng anak ko na day) IV lines and tubes. diaper for more
kailangan kong c) Fever than 24 hours (1
isugod siya (temperature over 3) Let the mother day) over
agad sa ospital” 38°Celsius)  perform 38°Celsius) 
as verbalized d) The child has independently the d) The child has
by the mother. not peed in their procedure the you not peed in their
diaper at least one have taught in caring diaper at least
Objective: time every 4-6 for her post-operative 3) Implementing a one time every 4-
-Request for hours child. teach back method 6 hours
information helps the mother
-The mother - 2). Mother will enhance her skill
shows signs of identify ways to and confidence in -After 4 hours the
anxiousness care for her child caring her child post- mother
who had a pull- 4) Use resource operative child. enumerated

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 Saint Mary’s University
Bayombong, Nueva Vizcaya
SCHOOL OF HEALTH and NATURAL SCIENCES
NURSING DEPARTMENT

through surgery teaching materials, ways to care for

and explain the audiovisuals as her child who had
reason why these available. 4) Specifically a pull-through
actions are designed materials surgery and
necessary such as:   can facilitate the explain the
patient’s learning. reason why these
a) Surgical wound actions are
care (cleaning, necessary like
application of the following:
gauze and a) Surgical
dressing) wound care
(cleaning,
b) Administer the application of
medications gauze and
prescribed by the dressing)
doctor. b) Administer the
medications
prescribed by the
Long Term: doctor.
-After 2 weeks the
parents will both be Long Term:

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 Saint Mary’s University
Bayombong, Nueva Vizcaya
SCHOOL OF HEALTH and NATURAL SCIENCES
NURSING DEPARTMENT

participating in the - After 2 weeks

post operative care the parents are
of the child: both participating
a) Continues in the post
monitoring routine operative care of
bowel attitude. the child:
b) Monitoring of a) Continues
their infant for monitoring of
danger signs and their infant for
c) Post operative danger signs and
care ( wound care routine bowel
& medication attitude.
administration).
Table 6.3. Nursing Care Plan for Deficient Knowledge

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