Renato A Magtibay September 22, 2023

NURSING CARE PLAN CASE: RISK OF INFECTION

PATIENT NAME: OYBAD

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

SUBJECTIVE: "Risk for Infection 1. Assess the patient's Emphasize the Continuously assess
The hand hurts and related to hand for any signs of importance of hand the patient's
cannot move properly. compromised skin infection, such as hygiene for all condition and
integrity and invasive redness, swelling, healthcare providers, progress in reducing
procedures." warmth, or discharge. visitors, and the patient. the risk of infection.
OBJECTIVE:
The wound seems to be 2. Monitor the Ensure proper use of PPE
still swollen, but he patient's vital signs, (gloves, masks, gowns)
can't move it much. including as indicated.Emphasize
temperature, as an the importance of hand
elevated temperature hygiene for all
may indicate an healthcare providers,
infection. visitors, and the patient.
Ensure proper use of PPE
3.Educate the patient (gloves, masks, gowns)
on proper wound care as indicated.
and hygiene practices,
such as keeping the
hand clean and dry,
changing dressings as
needed, and avoiding
any activities that may
introduce bacteria
into the wound.
Renato A Magtibay September 22, 2023

NURSING CARE PLAN CASE: PAIN

PATIENT NAME: DANIEL SATILICIS

ASSESMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

SUBJECTIVE: "Impaired Physical 1. Assess the patient's Pain Assessment: Continuously assess
His arm hurts and Mobility related to pain level and provide the patient's pain
can't move very well limited range of appropriate pain Continuously assess the and evaluate the
motion and management patient's pain using a effectiveness of pain
OBJECTIVE: immobilization." interventions, such as pain scale (e.g., 0-10 management
He has difficulty administering numeric rating scale) and interventions.
moving and prescribed pain document pain
sometimes his hand medications or characteristics. Modify the care plan
hurts when he moves applying ice packs to as needed based on
or rushes. reduce swelling and Ask the patient to the patient's
discomfort. describe the pain (e.g., response to
interventions and
2. Monitor the location, intensity,
any changes in their
patient's quality, radiation,
pain status.
neurovascular status exacerbating and alle
regularly, including Ensure that the
assessing for any Medication patient's pain is well
changes in sensation, Management: managed and that
movement, or their comfort and
circulation in the Administer analgesic quality of life are
affected arm. Report medications as improved.
any abnormalities to prescribed by the
the healthcare physician. Monitor and
provider immediately. document the
effectiveness of pain
3. Educate the patient medications.
on proper cast care,
including instructions Educate the patient
on keeping the cast about the importance of
clean and dry, reporting pain promptly
avoiding activities to ensure timely
that may cause administration of
damage to the cast,
and recognizing signs
of complications, such
as increased pain,
swelling, or foul odor.
Renato A Magtibay September 22, 2023

NURSING CARE PLAN CASE: CESAREAN SECTION

PATIENT NAME: ATIENZA

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

SUBJECTIVE: Risk for Infection After 2-3 hours of Wound Care: Monitor Continuously assess
related to surgical nursing intervention, the surgical incision the patient's condition
The patient verbalises, incision. Acute Pain the patient will site for signs of and evaluate the
"I feel severe pain in related to surgical verbalize decrease infection (redness, effectiveness of
my stomach area. incision and uterine intensity of pain from swelling, drainage). interventions
contractions. 9/10 to 3/10
Impaired Mobility Keep the incision site
related to clean and dry, and
postoperative change dressings as
recovery. Risk for needed.
Thrombophlebitis
OBJECTIVE: related to immobility. Administrator
Take the patient's prescribed antibiotics
vital signs to see if BP, and analgesics as
pulse rate, ordered.
temperature are Pain Management:
normal. Assess the patient's
pain using a pain scale
BP:100/70 (e.g., 0-10 numeric
TEMP: 36.6 rating scale).
PR: 70
RR:17 Administer pain
medications as
prescribed and
monitor for side
effects.

Encourage the patient

to use relaxation
techniques and deep
breathing exercises
for pain relief.

Mobility and
Ambulation:

Assist the patient with

early ambulation as
tolerated.

Encourage leg
exercises and ankle
pumps to improve
circulation and
prevent
thrombophlebitis.