NURSING CARE PLAN

Assessment Risk Factor: Presence of surgical incision on the mid lower abdomen Diagnosis Risk for infection Planning After 15 minutes, the patient will be able to identify interventions to prevent or reduce risk of infection. Implementation Intervention 1. Stress proper hand washing techniques Rationale 1. To prevent spread of bacteria and cross contamination 2. To reduce risk of nosocomial infection Evaluation

2. Instruct patient to carefully keep dressings dry and clean

3. Emphasize personal hygiene

3. To limit potential source of infection

4. Advise SO to maintain clean equipments or things of patient and to provide clean bed and surroundings

4. To reduce risk of acquiring infection from microorganisms

NURSING CARE PLAN

Assessment Subjective: Masakit itong sugat ko lalo na pag naigagalaw ko as verbalized by the patient pain scale of 7/10 Objective: facial grimace when moving guarding behavior on the incision site incision on mid lower abdominen Diagnosis Acute pain related to traumatized nerve endings secondary to surgical incision Planning After 30 minutes, the patient will demonstrate use of relaxation techniques and diversionary activities as manifested by verbal reports of relief of pain Implementation Intervention 1. Position the patient comfortably in bed Rationale 1. To relieve abdominal muscle tension and enhance circulation 2. Can minimize feeling of pain Evaluation

2. Divert attention from pain by initiating conversation 3. Instruct patient to use relaxation techniques such as deep breathing exercises, guided imagery, visualization and music 4. Instruct patient to have adequate rest periods

3. To relieve muscle and emotional tension and may enhance sense of control

4. To promote comfort and prevent fatigue

5. Encourage verbalization of feelings about pain

5. To note for changes from previous reports

NURSING CARE PLAN

Assessment Objective: presence of incision on the mid lower abdomen Presence of tenderness Diagnosis Impaired skin integrity related to surgical incision Planning At the end of 15 minutes, the patient will be able to verbalize understanding on ways how to prevent complications of skin breakdown. Implementation Intervention 1. Instruct the patient to wear loose-fit clothing Rationale 1. Constrictive clothing can increase risk of skin breakdown 2. Splinting equalizes pressure on the area, minimizing risk for dehiscence or rupture. 3. Long finger nails used for scratching are more likely to cause skin trauma and aggravate itching 4. To prevent contamination of wound Evaluation

2. Instruct patient to splint abdominal incision with pillows during coughing and movement 3. Instruct patient not to scratch skin near the incision site and keep fingernails short

4. Instruct patient not to touch wound

NURSING CARE PLAN

Assessment Subjective: Paano ba yung cancer?, as verbalized by the patient Objective: Observed curiousness of patient regarding his condition Diagnosis Knowledge Deficit (learning need) regarding illness related to lack of information Planning After 30 minutes, the patient should be able to verbalize understanding on his condition and demonstrate some self care management. Implementation Intervention 1. State objectives clearly in learners terms 2. Provide information relevant only to his case 3. Use short and simple sentences and concepts, repeat and summarize the information. 4. Discuss one topic at a time, avoid giving too much information in one session. Rationale 1. To meet learners needs . Evaluation

2. To prevent information overload 3. For patient to understand better.

4. For clearer and better understanding of patient.

5. Provide for feedback and evaluation of learning or acquisition of skills

5. To facilitate learning

NURSING CARE PLAN

NURSING CARE PLAN