NUSRING CARE PLANS

January 8,2014

Assessment
Objective:
Scheduled for
Anathropic
Nephrolitotomy,
Pyelonephrolithotomy

Needs

R
E
M
E
D
I
A
L

Keep on glancing at
the OR staffs

Constant change in
position

Jiggling of leg

C
A
R
E

Vital signs:
BP-130/60mmhg
HR-86bpm
RR-22cpm

N
E
E
D
S

To identify
and accept
positive
and
negative
(The
TwentyOne
Nursing

Diagnosis
Mild Anxiety
related to
scheduled
surgical
operation

Scientific Basis:
Anxiety is a
multisystem
response to a
perceived threat
or danger. It
reflects a
combination of
biochemical
changes in the
body, the
patients
personal history
and memory,
and the social
situation.(Rebecc
a J. Frey,2010)

Goal
At the end of 30 minutes
span of care, patients
anxiety will be reduced
as evidenced by:
a. Appears relax
and calm
b. No physical signs
of anxiety;
jiggling of legs,
cold clammy
skin, and profuse
sweating
c. Verbalization of
relief

Interventions

Rationale

-Monitor vital signs

-To identify physical

responses
associated with
both medical and
emotions condition.
-This can point to
the client level of
anxiety to
determine
appropriate
approaches to
relieve anxiety

-Observe the
behaviours of the
client

-Encourage client to
express feelings of
concern about the
surgery.

-This can clarify

meaning of
feelings/actions of
client.

-Discuss to the
client what to
expect in surgery,
telling who else are
present in the OR,
and how long the
procedure would be

-This could help the

client prepare for
the experience and
gain a sense of
control.

-Reassure client of
safety in the OR.

-Reassurance
relaxes the clients
psychosocial aspect
and relieves fear of
the unknown

Evaluation
Goal met, patients
anxiety was
minimized as
evidenced by the
patients calm
appearance, no
further manifestation
of anxiety, and
patient reported
anxiety is reduced to
a manageable level.

Problems
Theory
by Faye
Glenn
Abdellah)

-Provide comfort
measures by
positioning the
client

-providing comfort
can help client
lessen her anxiety

January 08,2014
Assessment
Objective cues:

Vital Signs
BP:110/90mmhg
HR:83bpm

Needs

Diagnosis

S
U
S
T
E
N
A
L

Risk for pulmonary

distress related to
induction of
anesthesia

Introduction of
General
Anaesthesia

C
A
R
E

Patient semiconscious

N
E
E
D
S
To recognize the
physiologic
responses of the
body to disease
condition.
(The Twenty-One
Nursing Problems
Theory by Faye
Glenn Abdellah)

Scientific basis:
Induction of general
anesthesia is
detected by a high
sensory level and
rapid muscle
paralysis which can
result to the loss of
airway patency due
to the relaxation of
the pharyngeal
muscles and
posterior
displacement of the
tongue. The ability to
manage secretions is
lost, and saliva and
mucous can obstruct
the oropharynx.
The loss of the cough
reflex allows
secretions (or
refluxed gastric
contents) onto the

Goal
After the surgical
procedure patient
will be free from
pulmonary distress
as evidenced by:

Interventions
-Proper
positioning of
the client

a. Normal O2
saturation
b. Patients
vital signs is
within
normal
range

c. Normal
breathing
pattern
d. No cyanosis

-Coordinate
with the OR
personnel

Rationale
-As soon as the
patient has been
injected with
anesthesia,
patient is
positioned on her
back. If high dose
is inducted, head
and shoulder is
lowered.

-The circulating
nurse manages
the OR and
protects the
patients safety
and health by
monitoring the
activities of the
surgical team,
checking the OR
conditions and
continually asses
the patient for
signs of injury and

Evaluations
Goal met, during the
surgical procedure
patient is free from
pulmonary distress as
evidenced by:
a. Normal O2
saturation
b. Patients vital
signs is within
normal range
BP=120/80m
mhg
HR=83bpm
c. Normal
breathing
pattern
d. No cyanosis

vocal cords,
causing
laryngospasm, or to
enter the trachea
and lungs causing
bronchospasm and
ultimately
infection. These
effects result in
airway obstruction
(http://www.patie

nt.co.uk/doctor/im
portantcomplications-ofanaesthesia).

implementing
appropriate
interventions.
- Encourage
early
ambulation

-To promote
circulate and
prevent from
developing
thrombophlebitis.

-Deep
Breathing and
Coughing
exercise

- To improve
pulmonary gas
exchange or to
maintain
respiratory
function and help
prevent
pneumonia after
surgery.

January 14,2014
Assessment

Needs

Diagnosis

Goal

Interventions

Risk for infection

related to
presence of open
wound.

After the first 24 hour

from the surgery,
patient will remain
free from infection as
evidenced by:

-Monitoring vital
sings

-Vital Sings:
BP:110/90mmhg
HR:85bpm

B
A
S
I
C

-Vital signs serves

as a baseline data

-Patient semiconscious

T
O

-Strict aseptic
technique
emphasized on
the wound
dressing.

-To prevent the

wound from
infection and from
contamination.
(Rothrock,2003)

-With incision on the

abdomen

A
L
L

Objectives:

P
A
T
I
E
N
T
S
N
E
E
D
S

Scientific Basis:
Surgical sepsis
prevents the
contamination of
surgical wounds.
The patients
natural skin flora
or a previously
existing infection
may cause postop wound
infection.
(Smeltzer,2008)

a. Vital signs
within normal
range
b. No redness on
incision site
c. No
inflammation
on incision site

Rationale

-Check the wound -To prevent the

for signs of
wound further
infection.
infection.
(Rothrock,2003)
-Daily wound
Dressing

Collaborative:
Administration of
medication as
ordered by the
Phycisian.
Antibiotic

-To keep the

wound always
clean and prevent
from infection.

-To make the

wound heal faster
and prevent
infection to the
wound. (Nurses

Evaluation
Goal met the patient
was free from infection
as evidenced by:
a. Patients Vital signs
is within normal
range
BP: 110/90mmhg
HR:84bpm
RR:19cpm
b. No redness on
incision site
c. No inflammation on
incision site.

To promote
safety
through the
prevention of
accidents,
injury, or
other trauma
and through
the
prevention of
the spread of
infection.
(The TwentyOne Nursing
Problems
Theory
by Faye
Glenn
Abdellah)

Prohylaxis for the

wound.

Pocket Guide 12th

edition)

January 08, 21014

Assessment
Objectives:
-

Incision on
abdomen

Appears weak

With foley
Catheter

Limited range of
motion

Pain upon
movement

-Guarding behaviour
-Restrictive
movements

Needs
R
E
S
T
O
R
A
T
I
V
E

Diagnosis
Impaired mobility
related to fear of
post-op surgical
incision as
evidenced by
restricted
movements.

Scientific Method:
Most surgical
patients are
encouraged to be
out of bed as soon
N
as possible. Early
E
ambulation
E
reduces the
D
incidence of postS
operative
complication
To accept the (Oetker-Black,
optimum
Jones, Estok et al,.
possible
2003;Rothrock
goals in the
2003 Pauline Paul,
light of
Beverly
limitations,
Williams.Brunner
physical and & Suddarth's
emotional.
Textbook of
Canadian Medical-

Goal
After 8 hours span
of nursing care,
Patient will
manifest
improved activity
intolerance as
evidenced by:
a. Participation in
ADL; grooming
b. Ambulation
from bed to chair
without
assistance if
possible.

Interventions
Rationale
-Vital sings taken -Serves as baseline
and recorded
data
-Assist patient in
getting out of
bed

-Help patient move

on his own

-Encourage
patient to do
much hygiene
routine

-This will help

patient to restore
his sense of selfcontrol and
prepares the
patient for
discharge.
-A regular exercise,
appropriate fluid
intake, helps patient
to avoid downward
of mobility

-Provide
information
upon the effects
c. Passive range of of lifestyle and
motion
overall health
status on activity
d. Isometric
intolerance
exercise
-Perform passive -These exercise
isometric
increase strength
exercise to
patient

Evaluation
Goal partially met,
the patient
manifested
improvement in
activity in tolerance
as evidenced by:
a. Patient being able
to perform activities
of daily living
independently and
grooming
b. Ambulates from
bed to chair with
assistance
c. Performs passive
range of motion and
isometric exercises.

(The TwentyOne Nursing

Problems
Theory
by Faye Glenn
Abdellah)

surgical Nursing)

INDEPENDENT
OBJECTIVE

Presence of
surgical
Incision

(+)
discomfort

skin warm to
touch

Pain scale
= 8/10

(+) guarding
behavior

(+) facial
grimace

Irritable

SUSTENAL
CARE
NEEDS

By.
Faye
Glenn
Abdellahs
Theory

Acute Pain
related to
disruption of
skin and
tissue
secondary to
presence of
surgical
incision

(Nurses
Pocket guide
th
12 edition)

Acute pain/
Impaired
comfort may
be related to
surgical
trauma,
effects of
anesthesia,
hormonal
effects,
bladder or
abdominal
distention,
possibly
evidenced by
verbal reports,
guarding or
distraction
behaviors,
irritability,
facial mask of
pain.

V/S taken as
follows
B/P:130/100
PR:96
RR:26
Temp: 36.7

(Nurses
Pocket guide
th
12 edition,
pg.957)

- After 8 hours span of

nursing care, Patient
will be able to :

- Monitor the Vital Signs

- to identify physical
responses associated
with both medical and
emotional conditions,
also to establish a
baseline data

-Bedside care such as

regulating the IVF,
arranges the bed linens,
and ask patient for any
problems.

- to promote comfort and

to enhance patients self
esteem

-Assess quality,
characteristics, severity
of pain.

-to establish baseline

data for comparison in
making evaluation and to
assess for possible
internal bleeding.

-Provide comfortable
environment by
changing the bed linens,
position the patient to
her comfort side, and
instruct her to do
breathing exercises to
control the pain.

-Calm environment and

comfortable measures
helps to
decrease the anxiety of
the patient and promote
likelihood of decreasing
pain.

-Instructed to put pillow

-To check for diastasis

a.) Verbalize that pain

intensity is decreased
from 8/10 to 4/10.
b.) Demonstrate use
of relaxation skills and
diversional activities
such as socializing
with others, watching
TV, listening to music
etc.

-Goals partially met.

The patient was able to
Verbalize that pain is
decreased from the
scale of 8/10 to 5/10 as
evidenced by the
patients being able to
smile while socializing
with her family. Patient
was also able to
demonstrate comfort
measures to alleviate
pain such as by doing
breathing exercises and
by using relaxation
skills like watching
comedy movies.

on the abdomen when

coughing or moving.

recti and protect the area

of the incision to improve
comfort. And to initiate
nonstressful musclesetting techniques and
progress as tolerated,
based on the degree of
separation.

-Encourage diversional
activities such as
socialize with her family,
watch TV, listen to
music, etc.

-to distract attention and

to assist the patient to
explore methods for
alleviation of pain.

DEPENDENT:
-Administer Analgesic as
per doctors order

-to relieve pain felt by the

patient.
Indicated for the shortterm ( 5 days)
management of
moderately severe acute
pain that requires
analgesia at the opioid
level, usually in a
postoperative setting.
(Nurses Pocket Guide
th
12 edition,pg.685-590)