ACTUAL NURSING CARE PLAN
ASSESSMENT EXPLANATION OF
S>”Medyo agnerbios ak
nga maoperaan”
O> vital signs taken as
follows:
-BP=140/80mmHg
-RR=20cpm
-PR=61bpm
-T=36.5oC
> non-conversant but
cooperative
> Able to do ADL as to bed
mobility, feeding.
>on NPO diet
>not in respiratory distress
Nursing diagnosis:
Mild anxiety related to
upcoming surgical
operation. (Prostatectomy)
THE PROBLEM
Renal function Test are
advanced
indicating advanced BPH
(Benign Prostatic
Hyperplasia)
urinary obstruction
urgency, frequency,
hesitancy, decreased urine
stream, and dribbling
surgical operation
(prostatectomy) is indicated
to prevent BPH
mild anxiety to scheduled
surgical operation
OBJECTIVES NURSING
INTERVENTIONS
STO: Dx:
Within 3 hours of nursing > Monitored vital signs and
interventions, the patient record accordingly.
will be able to identify
ways to deal with and >Assessed respiratory
express anxiety. status.
Tx:
LTO: >Established rapport.
Within 8 hours of nursing
interventions, the patient
will be able to appear > Assisted patient on
relaxed and report anxiety comfortable position.
is reduced to a manageable
level. >acknowledged patient’s
verbalization of anxiety.
>IVF regulated and
checked for patency.
> Anticipated and attended
to needs
Edx:
> Encouraged on the
following:
- to verbalize feelings and
discomfort
- to take rest and sleep
- to have diversional
activities like reading
RATIONALE EVALUATION
STO:
> Serve as a baseline data After 3 hours of nursing
intervention, the patient
was able to identify ways to
> To know if the patient is deal with and express
in respiratory distress. anxiety like conversing
with SO’s and reading
newspaper.
> To gain trust and
cooperation.
> Helps to alleviate feeling
of anxiety. LTO:
After 8 hours of nursing
> to assure that anxiety is a interventions, the patient
normal feeling. was able to appear relaxed
and report anxiety is
> to avoid circulatory reduced to a manageable
overload. level.
> For patient not to strain
self.
> to know appropriate
nursing interventions to be
done.
> provide comfort to the
body causing relief of
anxiety
> for patient to address and
reduced feelings of anxiety
 newspaper and conversing
with SO”s

> Emphasized the > For patient to comply

importance of therapeutic with the pharmacological
regimen. interventions.
> Help alleviate the anxiety
> Emphasized the presence of the patient
of Significant others
> Informed on NPO Diet. >for patient to understand
the reasons for NPO
preoperatively

ASSESSMENT
O>febrile, 38.5
>swelling surgical incision
>redness noted on the
surgical wound
> wet surgical dressing
> weakness in appearance
>irritable
>restless
Nursing diagnosis:
Risk for infection related to
traumatized tissue
secondary to post
prostatectomy.
EXPLANATION OF
THE PROBLEM
Prostatectomy
Surgical incision
Tissue trauma
Opening of tissue
Possible Site of entry of
pathogens causing infection
Risk for infection
POTENTIAL NURSING CARE PLAN
OBJECTIVES
STO:
Within 8hours of nursing
interventions, the patient
will be able to identify
proper actions to prevent
possible occurrence of
infection and verbalize
understandings of
individual causative or risk
factors of infection.
LTO:
After 2 days of nursing
interventions, the patient
will achieve timely wound
healing, be afebrile, and
identify interventions to
prevent or reduce infection.
NURSING
INTERVENTIONS
Dx:
> Monitor vital signs.
> observe for localized
Signs of infection at
insertion sites and at wound
site
> assess surgical incision
Tx:
>Establish rapport.
> Assist patient on
comfortable position.
> maintain sterile technique
in changing wound
dressing
>perform TSB
> Acknowledge
patients question regarding
infection cause and control
>Give due antibiotics
Edx:
> Encourage on the
following:
- to increase fluid intake.
RATIONALE
> vital signs are important
baseline data because it
proves possible infection
> to assess causative and
contributing factors of
infection
> to note presence of
infection and wound
complications
> To gain trust and
cooperation.
> for patient not to strain
self.
> to reduce or correct
existing infection risk
factors.
> to address fever
> gives knowledge and
background to patient
regarding the cause and
effects of infection
> Helps prevent infection.
> Keep fluid and
electrolyte balance of the
body
EVALUATION
STO:
After 8hours of nursing
intervention, the patient
will be able to identify
proper actions to prevent
infection and verbalize
understandings of
individual causative risk
factors of infection.
LTO:
After 2 days of nursing
interventions, patient will
be able to achieve timely
wound healing, be afebrile
and identify interventions
to prevent or reduce
infection such as proper
cleaning of wound
aseptically.
 - to take rest and sleep
>emphasize necessity of
taking antibiotics
> instruct patient and
significant others on proper
prevention of infection
> helps the patient’s body
to regain strength
> for patient to cooperate in
taking meds for infection
control and prevention
> to promote wellness and
prevent infection
 ACTUAL AND POTENTIAL NCP

Patient’s case: PROSTATECTOMY

Submitted to:

Mr. Alimbuyao, Jeffrey

Submitted by:

Buangan, Jervise

July 3, 2008