University of St. La Salle NURSING CARE PLAN Name: R.B. Age: 19 yrs.

old Sex: Male Chief Complaints: Swelling in the Posterior Chest Assessment Actual / Abnormal Findings: Temp: 37.0C PR: 77bpm RR: 30cpm BP: 100/50mmHg Decreased Albumin level 2.40g/dl Decreased K level 3.30meg/L Decreased Hct count 0.25L/L Decreased Hgb count 82g/dl Decreased RBC count 2.89 10^9/L Increased WBC count 19.1 10^g/L Increased no. of Monocytes 10% Abscess with approximately 5cmx3cm at right posterior thorax Pale conjunctiva Nursing Diagnosis Rationale Desired Outcomes After 2 days of nursing intervention, the client will be able to: Medical Diagnosis: Soft Tissue Abscess Posterior Thorax Attending Physician:_____________________ Student Nurse: Leo Mar D. Makilan Year and Section: BN3B Group 2 Nursing Intervention Independent: Justification of Care Evaluation After 2 days of nursing intervention, the client will be able to:

Impaired tissue integrity R/T an infection AEB pain at the right posterior thorax with the pain scale of 3, increased number of WBC, Monocytes, abscess

2. Note poor hygiene 2. It may be or health practices. with approximately impacting tissue 5cmx3cm at right health posterior thorax. 3. Assess 3. Some areas of a environmental Exposure to infection country or city location of home may be susceptible and work or Pathogens may enter to certain disease school, as well as through open wound, conditions or 2. Demonstrate recent travel. respiratory tract, GUT. environmental Definition: Damage to behaviors and pollutant. mucous membrane, lifestyle changes to 4. Monitor laboratory Increase number of WBC 4. Changes indicative corneal, promote healing studies. in the blood of healing or integumentary, or and prevent subcutaneous tissues. presence of complication or The WBC will go to the infection, recurrence. infected site and engulf complications. Source: Deonges, M. (phagocytosis) the 5.Emphasize need for E., Moorhouse, M. F., pathogens and the 5. To optimize

Predisposing factor: Age Workplace Low socioeconomic status Alcohol intake Precipitating factor: Sleep late at night Dont have vitamin supplement

1. Verbalize understanding of condition and causative factors.

1. Identify the 1. Suggest treatment options, as well as underlying clients desire and condition or ability to protect pathology involved self, and potential in tissue injury.
for recurrence of tissue damage.

infected cells Pain at the posterior & Murr, A. C. (2011). Nurse's Pocket thorax with the pain Guide: Diagnoses, scale of 3. Carried in different part Prioritized of the body for excretion Strength: Family Support Interventions, and (lymph nodes) Rationales (12 ed.). Weakness: Financial Philadelphia: F.A. Support & Lack of In case of severe Davis. knowledge about the infection, germ and condition

adequate nutritional and fluid intake.

healing potential.

infected cells may form a pus-filled abscess in the deep in the body tissues.

Source:
Johnson, J. Y. (2010). Handbook for Brunner & Suddarth's textbook of medicalsurgical nursing. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.