General Santos Doctors’ Medical School Foundation, Inc.

Bulaong Subd., Brgy. West, General Santos City, Philippines

Telephone Nos. (083) 552-9793 | gsdmsfihumanresource@gmail.com

Alimosa, Kylle E. BSN2-C

NURSING CARE PLAN

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
Risk for Injury related Short term: INDEPENDENT Short term:
SUBJECTIVE: to impaired mobility After 8 hours of nursing 1. Continuously To assess the patient's After 8 hours of nursing
Patient reports secondary to spinal intervention, the patient monitor the physiological status, detect interventions, the goals
numbness and lack anesthesia during will be able to: patient's vital early complications, and were met.
of sensation in the varicocelectomy 1. Prevent injury signs, including maintain oxygenation
lower limbs due to surgery as evidenced during surgery by blood pressure, during spinal anesthesia. The patient remains free
spinal anesthesia. by absence of ensuring the heart rate, and from injury during the
Patient expresses sensation in the lower patient's safety oxygen saturation. varicocelectomy procedure.
concerns about not extremities on the operating 2. Maintain a vigilant To identify immediate Effective communication is
being able to feel or table. watch on the issues like bleeding or maintained between the
move the lower 2. Facilitate surgical site for infection, enabling timely scrub nurse, the patient, and
body during the Inference: communication any signs of intervention to prevent the surgical team throughout
surgery. This diagnosis is in line between the bleeding, infection, patient harm. the surgery.
with the clinical patient and the or complications. Vital signs and surgical site
OBJECTIVE: understanding that surgical team 3. Communicate any To ensure prompt observations are
Physical examination spinal anesthesia can regarding any significant response to patient consistently monitored and
shows decreased induce a temporary discomfort or changes or condition changes, reported as required.
muscle strength and loss of sensation and concerns. concerns to the maintaining safety and Documentation is complete,
absence of sensation muscle strength in the 3. Monitor the surgical team enabling swift decision- accurate, and facilitates the
in the lower lower body, which may patient's vital promptly. making. patient's post-operative
extremities. hinder the patient's signs and 4. Establish a clear Clear communication is care.
Patient's lower limbs ability to move or surgical site and effective vital due to spinal
remain immobile reposition themselves throughout the communication anesthesia's impact on
during the during surgery procedure. system with the sensation and mobility.
preoperative (Stoelting & Miller, 4. Document any patient before the Non-verbal cues enable
preparation. 2020). The absence of pertinent procedure, patient comfort and safety.
 General Santos Doctors’ Medical School Foundation, Inc.
Bulaong Subd., Brgy. West, General Santos City, Philippines
Telephone Nos. (083) 552-9793 | gsdmsfihumanresource@gmail.com

sensory feedback from observations and emphasizing non-

VITAL SIGNS: the lower extremities communicate verbal cues or
• T: 36.2 C can pose a risk, as the them to the signals to indicate
• P: 86 beats/min patient may be unable surgical team discomfort or
• R: 23 breaths/min to respond to promptly. concerns.
• B/P: 130/90 mmHg discomfort or make 5. Relay any patient To ensure immediate
necessary adjustments communication to action and adjustments,
to prevent injury the surgical team preventing complications
(Suresh & promptly to ensure and ensuring patient safety
Chandrashekara, their safety and during surgery.
2019). Therefore, well-being.
nursing interventions 6. Accurately To provide a
aimed at preventing document the comprehensive record of
injury and facilitating patient's vital the patient's condition
communication with signs, surgical site during surgery, enabling
the patient and findings, and any post-operative review and
surgical team are other observations ensuring that any issues
essential to ensure throughout the are addressed
their safety and well- procedure. appropriately.
being during the 7. Maintain thorough To aid smooth post-op
procedure. and clear records transition, helping
to ensure providers understand the
continuity of care surgical experience,
and facilitate monitor recovery, and
communication address post-op issues
with post-operative effectively.
care providers.

DEPENDENT
1. Collaborate with
 General Santos Doctors’ Medical School Foundation, Inc.
Bulaong Subd., Brgy. West, General Santos City, Philippines
Telephone Nos. (083) 552-9793 | gsdmsfihumanresource@gmail.com

the anesthesia
team and surgical To ensure the patient's
team to ensure the safety and prevents
patient's optimal musculoskeletal injuries or
positioning on the nerve compression due to
operating table. improper positioning.
2. Communicate with
the anesthesia
team regarding the To facilitate immediate
patient's response response to changes in the
to anesthesia and patient's condition,
any concerns the enhancing safety and well-
patient may have being during surgery.
during surgery.

References:
Stoelting, R. K., & Miller, R. D. (2020). Basics of Anesthesia (8th ed.). Elsevier.
Suresh, P. N., & Chandrashekara, K. Y. (2019). Spinal anesthesia: What the anesthesiologist should know. Journal of Anaesthesiology Clinical Pharmacology, 35(Suppl 1), S7–
S13. doi: 10.4103/joacp.JOACP_9_19
 General Santos Doctors’ Medical School Foundation, Inc.
Bulaong Subd., Brgy. West, General Santos City, Philippines
Telephone Nos. (083) 552-9793 | gsdmsfihumanresource@gmail.com

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Fear of Painful and Short term: INDEPENDENT Short term:
SUBJECTIVE: Difficult Urination After 2 hours of nursing 1. Explain the To help prepare the patient After 8 hours of nursing
Patient expresses related to recent intervention, the patient catheter removal mentally, reducing anxiety interventions, the goals
fear and anxiety catheter removal will be able to: procedure, and promoting informed were met.
about experiencing following surgery, 1. The patient will emphasizing that consent and cooperation.
pain and difficulty secondary to post- verbalize reduced some discomfort Assess the patient's anxiety
while urinating after operative recovery as fear and anxiety may be normal but level regarding painful and
catheter removal. evidenced by Patient regarding painful should be difficult urination. The
Patient reports expresses fear, and difficult transient. patient verbalizes reduced
anticipation of anxiety, and urination within 2 2. Provide To empower self-care, fear and anxiety within the
discomfort and anticipation of pain hours. information about reduce irritation risk, and 2-hour timeframe.
burning during while urinating 2. The patient will measures to enhance comfort. Evaluate the patient's ability
urination. independently minimize to urinate without significant
Inference: urinate without discomfort during pain or discomfort. The
OBJECTIVE: This diagnosis is in line significant pain or urination, such as patient can independently
Catheter has been with the clinical discomfort within drinking plenty of urinate without significant
removed as per the understanding that 2 hours. water and using a pain.
doctor's orders. spinal anesthesia can 3. The patient will warm sitz bath. Observe the patient's
Patient appears induce a temporary demonstrate 3. Reassure the To create a supportive demeanor and cooperation
anxious, tense, and loss of sensation and relaxation and patient that the environment, reducing during urination. The patient
cautious when muscle strength in the cooperation healthcare team is patient anxiety and demonstrates relaxation and
discussing catheter lower body, which may during the available to enhancing confidence. It cooperation during the
removal and hinder the patient's process of support them fosters trust and positive process.
urination. ability to move or urination. during urination communication during
reposition themselves and address any recovery.
VITAL SIGNS: during surgery concerns.
• T: 36.2 C (Stoelting & Miller, 4. Encourage the
• P: 86 beats/min 2020). The absence of patient to maintain To dilute urine and reduce
• R: 23 breaths/min sensory feedback from adequate fluid the likelihood of irritation or
 General Santos Doctors’ Medical School Foundation, Inc.
Bulaong Subd., Brgy. West, General Santos City, Philippines
Telephone Nos. (083) 552-9793 | gsdmsfihumanresource@gmail.com

• B/P: 130/90 mmHg the lower extremities intake burning sensations.

can pose a risk, as the 5. Explain the
patient may be unable importance of To promote compliance of
to respond to staying well- patient, preventing
discomfort or make hydrated for complications and aiding
necessary adjustments overall recovery healing.
to prevent injury and urinary
(Suresh & function.
Chandrashekara, DEPENDENT
2019). Therefore, 6. Offer prescribed To help alleviate
nursing interventions pain relief discomfort and pain during
aimed at preventing medication as urination, ensuring that the
injury and facilitating ordered by the patient's pain is managed
communication with physician if the effectively, promoting their
the patient and patient reports comfort and cooperation in
surgical team are significant pain the post-operative
essential to ensure during urination. recovery process.
their safety and well- 7. Endorse the To enhance continuity of
being during the patient to the ward care, patient
procedure. nurse and explain understanding, and
the timing and adherence, ensuring
dosage of pain comfort and enables clear
medication to the communication among
patient. healthcare providers.
 General Santos Doctors’ Medical School Foundation, Inc.
Bulaong Subd., Brgy. West, General Santos City, Philippines
Telephone Nos. (083) 552-9793 | gsdmsfihumanresource@gmail.com

Perry, A. G., Potter, P. A., Ostendorf, W., & Buppert, C. (2021). Nursing Interventions & Clinical Skills (7th ed.). Elsevier.