I.

NURSING CARE PLAN

Post-operative NCP

CUES DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective STG: Independent Patient is

– none airway After 4 hours of -Monitor vital -To establish a expected to be
clearance nursing signs baseline data free of
Objective: related to intervention, infection, as
surgery patient will be -Inspect dressing -Moist from evidenced by
anesthesia able to and perform drainage can be a normal vital
Temp: 36.4˚C understand wound care source of infection signs and
PR: 55 causative absence of
RR:22 factors, identify - Monitor white - Rising WBC purulent
CR:58 signs of blood count (WB indicates body’s drainage from
BP:110/70 infection and efforts to combat wounds,
report them to pathogens; incisions, and
health care normal values: tubes.
provider 4000 to 11,000
accordingly. mm3
- Monitor
LTG: Elevated -these are signs
After 2-3 days temperature, of infection
of nursing Redness,
intervention, swelling,
patient will increased pain,
achieve timely or purulent
wound healing, drainage at
be free of incisions
purulent
drainage or - Wash hands -Friction and
erythema, be and teach other running water
afebrile and be caregivers to effectively remove
free of infection. wash hands microorganisms
before contact from hands.
with patient and Washing between
 between procedures
procedures with reduces the risk
patient. of transmitting
pathogens from
one area of the
body to another

- Encourage fluid - Fluids promote

intake of 2000 ml diluted urine and
to 3000 ml of frequent emptying
water per day of bladder;
(unless reducing stasis of
contraindicated). urine, in turn,
reduces risk of
bladder infection
or urinary tract
infection (UTI).

- Encourage - These measures

coughing and reduce stasis of
deep breathing; secretions in the
consider use of lungs and
incentive bronchial tree.
spirometer. When stasis
occurs,
pathogens can
cause upper
respiratory
infections,
including
Independent: pneumonia.
– Administe
r -Antibiotics have
antibiotics bactericidal effect
that combats
pathogens
PRIORITIZED PROBLEM
1.Fluid volume deficit r/t post surgical fluid restriction

2.altered tissue perfusion r/t immobility during and after surgery

3.Fatigue r/t effect of surgery

4.pain r/t surgical incision