Scribd Logo
Upload

Welcome to Scribd!

  • 23 views

    NCP in Surgical

    Uploaded by

    Troy Miranda
    This nursing care plan is for a 71-year-old male patient admitted to the hospital with fever and chills. The patient has swelling and pain in his left leg. The nursing diagnosis is impaired skin integrity related to edema formation in the left leg. The plan is to assess the skin for integrity, color, moisture and texture; assess edema levels; encourage elevation of the legs; and provide wound care. Cefazolin is prescribed to treat potential bone or joint infection. The nurse's responsibilities include assessing for drug allergies and obtaining lab tests and cultures prior to administering Cefazolin.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    NCP in Surgical

    Uploaded by

    Troy Miranda
    23 views5 pages
    This nursing care plan is for a 71-year-old male patient admitted to the hospital with fever and chills. The patient has swelling and pain in his left leg. The nursing diagnosis is impaired skin integrity related to edema formation in the left leg. The plan is to assess the skin for integrity, color, moisture and texture; assess edema levels; encourage elevation of the legs; and provide wound care. Cefazolin is prescribed to treat potential bone or joint infection. The nurse's responsibilities include assessing for drug allergies and obtaining lab tests and cultures prior to administering Cefazolin.

    Original Title

    NCP IN SURGICAL

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This nursing care plan is for a 71-year-old male patient admitted to the hospital with fever and chills. The patient has swelling and pain in his left leg. The nursing diagnosis is impaired skin integrity related to edema formation in the left leg. The plan is to assess the skin for integrity, color, moisture and texture; assess edema levels; encourage elevation of the legs; and provide wound care. Cefazolin is prescribed to treat potential bone or joint infection. The nurse's responsibilities include assessing for drug allergies and obtaining lab tests and cultures prior to administering Cefazolin.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    23 views5 pages

    NCP in Surgical

    Uploaded by

    Troy Miranda
    This nursing care plan is for a 71-year-old male patient admitted to the hospital with fever and chills. The patient has swelling and pain in his left leg. The nursing diagnosis is impaired skin integrity related to edema formation in the left leg. The plan is to assess the skin for integrity, color, moisture and texture; assess edema levels; encourage elevation of the legs; and provide wound care. Cefazolin is prescribed to treat potential bone or joint infection. The nurse's responsibilities include assessing for drug allergies and obtaining lab tests and cultures prior to administering Cefazolin.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 5

    Republic of the Philippines

    UNIVERSITY OF EASTERN PHILIPPINES


    University Town, Northern Samar
    COLLEGE of NURSING and ALLIED HEALTH SCIENCES

    NURSING CARE PLAN


    Name of Patient: Maravilla, Daniel Belleza Date Admitted: 11/20/22 Chief Complaint: __Fever and Chills_________ Case Number:
    Age: 71 yrs old Gender: Male Civil Status: ______Married__________ Address: __Bobon, Northern Samar Ward: Surgical Ward

    ASSESSMENT NURSING SIENTIFIC OBJECTIVES/PLANNING NURSING SCIENTIFIC EVALUATION


    DIAGNOSIS RATIONALE INTERVENTIONS RATIONALE
    Subjective: “ Impaired Skin The skin is the After 4 hours of appropriate 1. Assess the skin for 1. Stratis dermatitis  
    Nag kikirot an Integrity related to body’s outermost nursing intervention, patient its rintegrity, color, affects the skin and
    akon wala na edema formation as defense system that will be able to: moisture and texture can causse
    siki” as stated evidenced by swelling keeps pathogens erythematous rashes
    by the patient of the left leg and feet from entering and 2. Assess the level of and edema
    and pain on the causing illness.  Patient maintains edema on the legs particularly on the
    Objectives: affected site. optimal skin integrity and cut on the ankle
    When the skin is hands, arms, legs,
    compromised due within limits of the and feet.
    BP: 140/70 disease, as evidenced 3. Encourage patient
    Temp: 38.2 ‘C to cuts, abrasions, to elevate legs and 2. Baseline data will
    ulcers, incisions, by intact skin.
    avoid putting them on help in the
    (+) swelling of and wounds, it  Patient will experience a dependent position evaluation of
    Left Leg allows bacteria to timely healing of for a long period of
    progress after
    enter causing wounds without time.
    (+) dry and pale interventions are
    infections. It is complications 
    skin 4. Encourage made.
    important that
    nurses understand  Patient will mobility 3. Putting legs on
    how to assess, demonstrate 5. Dress wounds as
    dependent position
    prevent, treat, and effective wound care  needed, avoiding
    will worsen leg
    educate patients on tight, constricting,
     Patient will verbalize and sticky dressings edema.
    impaired skin proper prevention of
    integrity.  4. Physical activity
    pressure injuries  6. Encourage patient helps promote
    to avoid wearing
    circulation and fluid
    constricting clothing
    drainage.
    7. Encourage proper 5. As needed,
    hydration wound will need to
    be dressed and
    cleaned. Sticky
    dressings may be
    difficult to remove
    and cause further
    damage.
    6. Tight clothing
    can further irritate
    skin damage and
    rashes.
    7. Dehydration can
    cause further skin
    injury due to skin
    dryness,structure
    and texture.

    Student Nurse: Miranda, Troy Albert N.


    Clinical Instructor: Gaybird P. Palacio, DMD, RN
    Republic of the Philippines
    UNIVERSITY OF EASTERN PHILIPPINES
    University Town, Northern Samar

    COLLEGE of NURSING and ALLIED HEALTH SCIENCES

    DRUG ANALYSIS
    Name of Patient: Maravilla, Daniel Date Admitted: 11/20/22 Chief Complaint: Fever and Chills Case Number:____________
    Age: 71 Gender: Male Civil Status: Married Address: Bobon, Northern Samar Ward: Surgical Ward__ AP: Dr. Perez__
    NAME OF SPECIFIC INDICATION CONTRAIND DRUG ADVERSE SPECIFIC NURSING RESPONSIBILITIES
    DRUG ACTION ICATION INTERAC REACTION PRECAUTI
    TION ON
    Generic Effective Semisynthetic, Hypersensitivit Drug:  Body as a Prescribing Assessment & Drug Effects
    Name:CEFAZO treatment for first-generation y to any Probenecid  Whole: Anaph cefazolin
    LIN bone and derivative of cephalosporin decreases ylaxis, fever, injection in  Determine history of
    joint cephalosporin C; and related renal eosinophilia, absence of hypersensitivity to
    antibiotic activity cephalosporins, penicillins,
    infections, antibiotics; elimination superinfections, proven or
    similar to that of and other drugs, before
    Brand Name: biliary tract cefazolin. pregnancy of seizure (high strongly
    Ancef infections, (category B), cefazolin. doses in suspected therapy is initiated.
    Activity against
    enocarditis lactation. patients with bacterial  Lab tests: Perform culture
    gram-negative
    prophylaxis organisms is renal infection or a and sensitivity testing prior
    Dosage:
    limited. to and during therapy.
    iV/IM 250 mg– and insufficiency).  prophylactic
    Bactericidal Therapy may be initiated
    2 g q8h, up to 2 treatment, GI: Diarrhea, a indication is
    action: pending results.
    g q4h (max: 12 respiratory norexia, unlikely to
    preferentially  Monitor I&O rates and
    g/d) tract and abdominal provide
    binds to one or pattern: Be alert to changes
    genital tract more of the cramps. Skin:  benefit to the in BUN, serum creatinine.
    infections, penicillin-binding Maculopapular patient and  If patient has had a reaction
    septicemia proteins (PBP) rash, urticaria. increases risk to penicillin, be alert to signs
    Route: and skin located on cell of of hypersensitivity with use
    Intravenous infections, walls of development of cefazolin. Cross-
    and surgical susceptible of drug- allergenicity between
    prophylaxis. organisms. This resistant cephalosporins and penicillin
    inhibits third and
    bacteria has been reported. Prompt
    final stage of
    bacterial cell wall attention should be given to
    synthesis, thus sHistory of onset of signs of
    killing the penicillin hypersensitivity (see
    bacterium. sensitivity, Appendix F).
    impaired  Promptly report the onset of
    Classification: renal diarrhea, which may or may
    ANTIINFECTI function, not be dose related. It is seen
    VE; ANTIBIOT patients on especially in patients with
    IC; FIRST- sodium history of drug-related GI
    GENERATION restriction. disturbances.
    CEPHALOSPO Pseudomembranous colitis, a
    potentially life-threatening
    RIN
    condition, starts with
    diarrhea.

    Patient & Family Education

     Report promptly any signs or


    Reference:
    STUDENT NURSE: Miranda, Troy Albert N. CLINICAL INSTRUCTOR: Gaybird P. Palacio DMD, RN______

    You might also like