Nursing Care Plan ( Potential )

Assessment

Diagnosis

Planning

Intervention

Evaluation

Subjective : Katatapos ko lang pong operahankahapon as verbalized by the patient. Objective : Post surgical incision

Risk for infection After 1hour of related to post surgical intervention the incision. patient will : identify the risk factors present in the clients condition. clients partial understanding about infection and its risk factors

Assess the clients perception, level of understanding and needs Ask the client or the relatives of the patient to clean their surroundings. instructed the patient and the relatives to do handwashing before and after cleaning the wound. Take the prescribed medicine given.

After 1hour of intervention the patient and the relatives identified the risk factors present in the clients condition, clients partial understanding about infection and its risk factors and they do all the interventions instructed.

Nursing Care Plan ( Actual )

Assessment

Diagnosis

Planning

Intervention

Evaluation

Subjective : Sumasakit ang operasyon ko as verbalized by the patient. Pain scale : 8 / 10 Objective : Post surgical incision With facial grimace Verbal report of acute pain

Acute pain related to post surgical as manifested by facial grimace and verbal report of acute pain.

After a series of interventions the patient should manifest a decrease in the pain scale of 8 / 10 to 3 / 10.

Assess the clients perceptions Encouraging verbal report of pain. Monitor VS and pain scale. Teach client divertional activities. Take the prescribed medicine given.

After a series of interventions the patient verbalized a decrease in the pain scale of 8 / 10 to 3 / 10 and manifested by loosing facial grimace.