Diagnosis Plan Nursing Rationale(why) Evaluation

Intervention
Risk for infection Patient will be -Wound Proper wound care After nursing
related to free of infection care/Dressing to prevent intervention,
abscess after her staying daily infection. Cleaned was free of signs
collection in in the hospital wound using of infections as
abdomen as with wound free betadine to evidenced by no
evidenced by of pus and minimize risk of pus formation
huge pus on granulated tissue introducing on wound and
wound and formation. additional bacteria granulated
drainage with and promotes tissue plus
necrotic tissue healing and reduce normal body
formation on risk infection. temperature of
wound, 37 degree
alteration in skin. -Vital signs every To identify early Celsius.
4 hours and signs of infection
report. such as elevated
body temperature,
increased heart
rate, low blood
pressure. Closely
monitor these vital
signs to report any
indications of
infection.

-Patient To teach patient

education and caretaker
about proper
wound care so
they can be able to
continue and
control infection
once discharge,
signs and
symptoms of
infection and
encouraging to
report any new or
worsening
symptoms.

Acute pain At the end of -Pain To access and After series of

related to nursing management identify the nursing
abdominal intervention assess patient location, intensity, interventions
wound abscess patient pain will pain scale quality and patient goals are
decrease to 0 -Encourage duration of the met as evident
pain scale. verbal report pain in order to of the patients
during and after provide decrease in pain
nursing appropriate pain scale from 8/10
 interventions. management. to 0/10 and
-Vital signs and Pain is highly positive verbal
report subjective and to report of patient
identify during
-Psychological effectiveness of evaluation.
assessment and the interventions.
patient Vital signs to
reassurance monitor high
-Encourage blood pressure and
verbal report increase heart rate
during and after which are both
nursing signs of pain and
intervention report to staff
-Advise nurse if these
breathing abnormalities
exercise happen as soon as
possible to provide
care to relieve
patient.
Assess her
emotional state
and psychological
well-being. Acute
pain can cause
anxiety, fear and
stress and reassure
Risk for anxiety To ensure patient -Assess and -To identify the At the end, goal
related to long anxiety and evaluate specific needs of met, patient’s
duration stress relieve patient’s the patient for her relieve her stress
hospitalization during her condition son and refer to was talkative,
manifested by staying in the church leaders and happy, make
her cry when she hospital town officer for jokes and
talks about her help. collaborate more
son. -Psychological -Actively listening during
support to patient concern conversation.
and validate their
-Supportive emotions.
family
involvement -To help alleviate
her distress and
promote overall
well-being by
allowing son to
visit her once a
week.
-Health
education on the
importance of -To help avoid
not stressing detrimental effects
herself on the immune
system leading to
 delayed wound
-Creating a calm healing.
environment -Ensure patient’s
room clean,
organized and less
noise to avoid
contribution to
anxiety.
Risk for deficient After 8 hours of - Assess vital -To detect changes After nursing
fluid volume nursing signs every 4 that may indicate interventions,
related to fluid interventions, hour to detect hypovolemia and patient input
loss via vomiting the patient will irregular and electrolyte and output were
and excessive maintain weak pulse. imbalances maintained as
fluid losses adequate fluid evidenced by
through the volume as the total
drainage evidenced by -Health educate -To provide input=1040mls
manifested by balance fluid patient to intake information on the and output =920
fatigue. intake and water as much as importance of mls.
output possible adequate Vital signs were
hydration, signs maintained
and symptoms of
dehydration such
as folded skin, dry
mouth, headache,
thirst etc and
support to prevent
to prevent fluid
loss.

-Monitor fluid -To detect

intake and unbalance output
output every 4 volume for early
hours. signs of deficient
fluid volume and
restore hydration
levels for
transportation of
nutrients,
nutrients and
oxygen to aid in
wound healing.

-A decrease in
patient output less
than 50mls per
hour may lead to
oedema or an
indication of
damage to other
organs especially
her kidney
regarding her
conditions since
she has other co-
morbidity(diabetic)
and highly at risk.
Increase in her
output compare to
input(dehydration)
can lower blood
pressure leading to
delay wound
healing.