CHAPTER THREE

PLANNING FOR PATIENT AND FAMILY CARE

This chapter deals basically with the nursing care plan. Planning involves writing of the nursing

care plan and it comprises of four components which are:

1. Setting of priorities

2. Establishing patient’s goals and outcome criteria.

3. Planning nursing strategies.

4Writing nursing care plan

SETTING OF PRIORITIES

This is the process of establishing preferential order of the nursing strategies. In effect, life

threatened problems are solved first.

ESTABLISHING PATIENT’S GOALS AND OUTCOME CRITERIAL

A goal in the nursing process is the expected outcome of nursing interventions. Outcome criteria are

statements that desire specified observable and measurable response of the patient. In view of this,

the achievement of the patient’s goals serves as the criteria for measuring the effectiveness of the

care plan.

PLANNING NURSING STRATAGIES

Nursing strategies are nursing activities performed to achieve the established goals for the patient. It

involves. It involves decision making and choosing one or more nursing strategies recognized as the

best and has the greatest probability of success.

The plan of care could be short or long term.

OBJECTIVES

SHORT-TERM PLANS OF THE CLIENT

1. To relieve his pain within 6 to 8 hour.
2. To allay his/family anxiety within 6 to 8 hours.
3. To promote sleep throughout hospitalization..
4. To prevent client from injuries postoperatively.

LONG-TERM PLANS OF THE CLIENT

1. To prevent postoperative infection.

2. To help him recover from the surgery without complications.

WRITING OF NURSING CARE PLAN

The nursing care plan is a written guide used by nursing staffs to meet the needs of the patient at a

given time. It is individualized and aids in the provision for the continuity of care. The nursing care

plan consists of the following:

1. Nursing diagnoses

2. Objectives and outcome criteria

3. Nursing orders

4. Evaluation

The nursing care plan on Mr. N.A is shown below in the table.
DATE NURSING OBJECTIVE/OUTCOME NURSING ORDERS NURSING DATE EVALUATION

/TIME DIAGNOSIS CRITERIA INTERVENTION /TIME

15/2/22 Pain (left inguinal Patient will experience 1. Reassure patient that he will 1) Patient was Patient verbalized

5:00pm region) related to gradual reduction of pain experience diminished pain within reassured that pain that there is

protrusion of within 40 minutes as 40 minutes. will subside with reduced pain and

intestines through evidenced by: proper nursing care, looked cheerful

the abdominal a. Verbalization of 2) Assess the level of pain. medication, and with stable vital

wall. decreased in pain. 3) Make client assume comfortable surgical intervention. signs. Goals fully

b. Relaxed facial position to assist in subsiding met.

expression. 4) Provide quite environment to 2) Client pain level

promote rest. was assessed (5 out of

5) Provide divisional therapy in the 10) using the pain

form conversation. scale and assisted.

3) Client was made to

assume a comfortable

position (supine)

which assisted in

16/2/22 Anxiety related to Patient will be relieved of
anxiety within 1 hour as
8:30am unknown outcome
evidenced by;
of surgery.
a. Patient’s statement of
feeling less anxious
b. Stable temperature ,
pulse, respiration and
blood pressure
c. Relaxed facial
expression
d. Patient agreeing to
undergo surgery
subsiding pain.
6) Patient was
engaged in series of
conversations.
1. Reassure client that competent 1. Client was Goal fully met, as
health team will perform the
reassured of good the patient
surgery and make it a success.
care from competent verbalized the
2. Provide comfortable bed and sit
closer to patient in a comfortable staff. feeling of been less
manner and educate patient on the
2. Client was anxious and has a
need for the surgery.
educated that the relaxed facial
3. Smile at patient and establish eye
to eye contact when speaking with surgery is to correct expression with
him.
the condition and stable blood
4. Invite patients who have
relieve him of his pressure (Temp;
undergone similar operation to
share their experience with the pain. 36.9 ◦C, Pulse; 80
patient.
3. Eye contact and bpm, Blood
5. Explain the condition and every
smiley face was Pressure;120/80mm
procedure for patient to understand.
expressed whiles Hg.
6. Allow and encourage patient to
speaking to him.
verbalize his feelings and concerns
4. Patients who have
about the surgery. undergone similar

operation was

7) Engage patient in a diversion invited to share their

therapy such as general experience.

conversation. 5. Client was told

8. Introduce the operation team to that a wound would

the client. be created at his left

inguinal region;

therefore he will

receive dressing each

day. Also he will

experience pain at

the incision site but

he will be relieved of

it through proper

nursing care.

6. Patient was

encouraged to

verbalize his
 concerns and

feelings on the

surgery.

7. Client was

engaged in a

conversation about

the nature of his

work.

8. The surgeon came

over to explain the

impending surgery to

the patient.

Sleep pattern Client will be able to sleep 1) Reassure client that the pain will 1) Client was

disturbance for about 1-2 hours during subside. reassured that with

(insomnia) related the day and 6-8 hours proper medication

to abdominal pain during the night within 48 and proper nursing

hours as evidenced by, a) management he will

2) Put client in a comfortable bed.
client verbalizing that he be relieved.

had sound sleep

uninterrupted.

2) Client was made

3) Give assisted warm bath (bed or comfortable in a bed

bathing) if needed. of clean bed lining.

3) Client was given

assisted warm

bathroom bath
5) Switch off bright light during
before going to bed
bedtime.
to ensure muscle

relaxation and

promote comfort.

5) Bright lights were

switched off to

provide a dim
 environment to

promote sleep.

16/2/22 Pain related to Client will be relief of pain 1. Reassure the patient that the pain Goals fully met as

8:00pm surgical incision. within 24 hours as will be managed adequately. client has dimin

evidenced by; 2. Assess patients level of pain ished pain as

a. Patient having relaxed 3.Check temperature, pulse, evidenced by;

facial expression respiration and blood pressure a. Client

b. Stable temp, pulse, 4. Position client in a recumbent verbalizing

respiration and blood position. reduction in pain.

pressure. 5. Observe the incisional site for b. Client having

c. Verbalization of no pain. tight adhesions, swelling and relaxed facial

bleeding. expression.

6. Explain the cause of pain to the

client that it as a result of the

incisional wound created during the

operation.

7. Administer prescribed analgesics

(Diclofenac 75mg,
 intramuscularly).

8. Employ diversion therapy

16/2/22 Impaired skin Client’s skin integrity will 1. Reassure client that wound will 22/11/1 Goals were

8:30pm integrity related to be restored within 10 days heal within 10 days. 0 partially met, as

surgical incision. as evidenced by: 2. Inspect wound for tight 10:00a client’s condition

a. Incisional site free from adhesions, swelling and bleeding. m was well for

offensive discharge. 3. Dress wound with alcohol using discharge and by

b. Well opposed skin aseptic technique. then, his wound

edges. 4. Ensure use of sterile materials for was not completely

c. Wound healing with wound dressing. healed.

minimal scar tissue. 5. Administer prescribed antibiotics

(Amoksiclav 1-2g intravenously at

4:00pm).

6. Encourage client to walk to

promote healing.
 16/2/22 Patients wound will be free 1) Reassure patient of a competent 1) Patient was Goal was met as

8:30pm High risk for from infection within 8 care. reassured of expected. Client

infection to days as evidenced by; competent care that had intact skin on

surgical incision. a) wound healing by first his wound will be the eight day.

intention 2) Observe the wound for signs of free from infection.

bleeding on the day of surgery.

2) Wound was under

observation for

bleeding until the

3) Check incision site daily for signs
first day of dressing.
of infection.
No bleeding or wet

dressing observed.

4) Wash hand before and after each

3) The incision site
procedure and dress wound after
was check daily for
three days under strict aseptic
swelling, and
technique.
reddnes and
 discharges but none

5) Check and record vital signs was observed.

especially temperature.

4) Hands were

7) Advice patient to avoid touching washed before and

and wetting dressed wound. after each procedure

performed on the
8) Administer prescribed client.
medication.

5) Vital signs were

check and recorded

within four hours

interval.

7) Client was

advised against
 touching and wetting

dressed wound to

avoid infection.

8) Prescribe

Metronidazole was

administered.

17/2/22 Self-care deficit Patient will bath unassisted 1) Reassure patient. 1) Patient was Goals were met.

8:30am (bathing) related within 72 hours as reassured that very Client was able to

to general body evidenced by the nurse soon; he will be able take his bath

weakness after observing patient carrying to bath by himself. unassisted by the

2) Assist patient to bath in twice a
the surgery. on activity unassisted. third day.
day until he is able to do so on his 2) Client was given
own. assisted bedbath

twice a day for two

3) Encourage the client to clean the
days.
mouth every morning and evening

before going to bed. 3) Patient was

 encouraged to clean

4) Place items frequently used by the mouth by

patient within his reach for easy brushing the teeth

accessibility every morning and

evening with tooth

5) Encourage patient to call for paste before
help/assistance if the need arises. returning to bed.

4) Items frequently

needed by patient

were placed by his

bed side to avoid

physical exertion in

an attempt to reach

them.

5) Patient was

encouraged to call
 for assistance when

in need of help.

17/2/22 Physical mobility Patient will be able to 1) Reassure client of competent 1) Patient was The goal was fully

8:30am impaired, related move out of bed within 48 nursing care. reassured he would met. Client resumed

to pain at the hours as evidenced by; be able to move his physical

incision site. a) Client verbalizing that about to perform his activities especially

he is able to walk. 2) Put patient in a position that is normal activities. walking on the
comfortable to him. ward.

b) The nurse observing that 2) Patient was

client has moved out of assisted to assume a

3) Assist patient to sit up in bed
bed. position which was
during meal time.
comfortable for him

and was change

4) Assist patient to undertake
every 2 hours
passive exercise.

3) Client was

assisted to sit up in

bed during meal

5) Prescribed analgesics to be
time to enhance
administered. physical mobility.

4) Client was

assisted to do

passive exercise by

raising the leg at the

incision site after

every six hours to

prevent deep vein

thrombosis.

5) Paracetamol was

administered as

prescribed to help

relief any pain.

 AMENDMENT OF NURSING CARE PLAN FOR PARTIALLY MET OUTCOME CRITERIA

DATE/ NURSING OBJECTIVE/OUTCOME NURSING ORDERS DATE/ EVALUATION SIGNATURE

TIME DIAGNOSIS CRITERIA TIME
17/2/22 Impaired Clients skin integrity will 1.Reassure client that 30 /11/10 Goals were fully met, as
skin integrity be restored within 10 days wound will heal within 12:10pm patient’s wound was
8:30am
related to as evidenced by: 10 days completely healed with
surgical a. Incisional site free from 2. Inspect wound for well opposed skin edges
incision offensive discharge. tight adhesives, and minimal scar
b. Well opposed skin swelling, bleeding and formation.
edges report.
c. Wound healing by first 3.Dress wound with
intention with minimal alcohol using aseptic
scar tissue techniques
4. Ensure use of sterile
materials and
instruments for wound
dressing.
5. Serve prescribed
antibiotics.
6. Encourage patient to
walk, to promote quick
healing.