ARELLANO UNIVERSITY

NURSING CARE PLAN

LEVEL III

Name of Student: Fernandez, Ma. Leslie Hay’s Date of Assignment: January 6/7,
2010 Ward: OB

Name of Patient: Maribel Icaro Tanio Age: 30 yrs. old Sex: Female Civil status:
Single

Diagnosis/Clinical Impression: post- operative NCP Date of

Admission: January 4 2010

Assessment Nursing Planning Implementation/Inter Evaluation

vention
(Cues) Diagnosis
With Rationale

Subjective: Risk for infection STG: Independent: Patient is expected

related inadequate to be free of
-none primary defenses After 4 hours of - monitor vital sign infection, as
secondary to nursing intervention, evidenced by
patient will be able
Objective: surgical incision
to understand
- inspect dressing and normal vital sign
perform wound care and absent of
causative factors,
- Dressing dry and Inference identifying signs of purulent drainage
intact - monitor white blood from wound,
infection and report
Due to an elective them to health care cell counts incision, and tubes.
- V/S taken as cesarean, patient provider accordingly.
skin were - monitor elevated
follows:
mechanically LTG: temperature, redness
swelling, increased
• T: 37 interrupted. Thus, After 2-3 days of pain or purulent
the wound is at nursing drainage at incisions
• PR: 60 risk of developing intervention,
infection. patient will achieve - wash hands and
• RR: 24 timely wound teach other care giver
healing, be free of to wash hands before
• BP: 110/80 purulent drainage contact with patient
or erythema, be and between
afebrile and be procedures with
free of infection. patient

- encourage fluid
intake of 2000-
3000ml /day (unless
contraindicated)

Dependent:
-Encourage the
patient to take
medication as
prescribed by doctor.