NURSING CARE PLAN

CUES

S: NURSING
HEALTH HISTORY
- 58 years old
male
- Lifestyle: smoker
& alcohol drinker
occasionally
O:
Vital signs:

Temp:
36.7 C
PR: 68
bpm
RR: b19
cpm
BP: 120/80
mmHg

(+) tracheostomy,
midline neck
(+) incision @
mandibular region
(+)wound healing

NURSING
DIAGNOSIS

Risk for
infection

SCIENTIFIC
RATIONALE

Presence of
incisions and
wound healing
Microorganism
invades the
incision and
wound
Activation of body
defenses
Inflammation

GOALS AND OBJECTIVES

NURSING INTERVENTIONS

GOAL:
By the end of the duty,
patient will demonstrate
no signs of infection.

During nursing
intervention, the student
nurse will:

OBJECTIVES:
By the end of the
nursing intervention,
the client will:
1. Not develop further
breaks from primary
defenses
2. Achieve timely wound
healing with no
infection.
3. Identify techniques to
prevent skin infection

Decrease in
monocyte status
Low immune
system

Risk for infection

1. Maintain strict asepsis

when performing
procedures to client.
2. Exercise proper hand
washing before and after
handling patient.
3. Check presence of
invasive devices and
monitor their present
condition.
4. Monitor vital signs
especially temperature
every 4 hours.
5. Check incisions/ wounds
for signs of infection.
.
6. Provide meticulous skin
care (cleansing bath)
7. Promote frequent and
adequate fluid intake.
8. Provide health teaching
on:
- proper hand washing
technique to client and
significant others
- Eat citrus fruits and green
leafy vegetables

RATIONALE

1. Asepsis will prevent

client from entry o
organisms thus,
protecting him from
infection.
2. Frequent, meticulous
hand washing greatly
decreases the chanced of
spearing infection.
3. Checking of condition
of lines or devices, their
duration of attachment
will help the nurse identify
possible sources of
infection, which she then
can remove.
4. Fever or hyperthermia
may indicate presence of
infection.
5. Skin and mucosa
provide first line defence
against microorganisms.
6. To prevent skin
breakdown this is a
possible way of infection.
7. To liquefy secretions
and facilitate
expectorations to prevent
stasis of body fluids and
promotes moist mucus
membranes.

EVALUATION

By the end of the

shift, the client
will be able to:
1. Not acquire
any infective
organism.
2. Cleanliness
and hygiene are
maintained at
wound sites and
bed sides.
3. Developed
resistance to
infection through
techniques

8. Techniques to prevent
or reduce risk of infection,
increase immune system
and to initialize learning
of patient.
S: Nahihirapan
siya ngumuya
kaya madalas
konti lang ang
nakakain niya as
verbalized by the
significant other
O: PHYSICAL
EXAMINATION
Vital signs:
Temp: 36.7 C
36.7 C
PR: 68 bpm
RR: b19 cpm
BP: 120/80 mmHg
- Difficulty in
swallowing
-Skin- Smooth,
dry skin with fair
turgor
- (+) muscle
wasting
Pale conjuctiva

Imbalanced
Nutrition:
Less than
Body
Requireme
nts related
to
decreased
intake and
secondary
to difficulty
swallowing

Presence of
incision @ left
mandibular &
sensation in the
throat

Difficulty of
swallowing

Decreased intake

Imbalanced
Nutrition: Less
than Body
Requirements

GOAL: By the end of the

duty, the client will
maintain nutritional
status and minimize
weight loss.
OBJECTIVES:
By the end of the
nursing intervention,
the client will:
1. Identify predisposing
factors that lead to
undernourishment of
patient
2. Follow the dietary
plan for patient
3. Verbalize
understanding of
causative factors and
necessary interventions
4. Demonstrate
progressive weight gain
toward goal

1. Teach significant other

the possible predisposing
factors that lead to
undernourishment of
patient.
2. Provide information
regarding the dietary plan
for the client
3. Suggest foods that are
preferred and well
tolerated by the patient,
preferably high-calorie and
high-protein foods.
4. Encourage adequate
fluid intake, but limit fluids
at mealtime
5. Suggest smaller, more
frequent meals.
6. Promote relaxed, quiet
environment during
mealtime with increased
social interaction as
desired.
7. Advocate high-protein
foods in between meals.
8. Encourage frequent oral
hygiene.

1. To initiate learning.
2. To provide ongoing
support and increase
likelihood of
accomplishing dietary
goals.
3. Foods preferred, well
tolerated, and high in
calories and protein
maintain nutritional status
during periods of
increased metabolic
demand.
4.Fluids are necessary to
eliminate wastes and
prevent dehydration.
Increased fluids with
meals can lead to early
satiety.
5. Smaller more frequent
meals are better tolerated
because early satiety
does not occur
6. A quiet environment
promotes relaxation.
Social interaction at
mealtime increases
appetite.

9. Position patient properly

at mealtime.

7. Snacks add protein and

calories to meet
nutritional requirements.

10.Encourage to verbalize

8. Oral hygiene stimulates

After the nursing

intervention, the
client will:
1. Identified all
predisposing
factors that lead
to
undernourishmen
t of patient
2. Followed the
dietary plan for
patient as
evidenced by the
following:
reported
decreasing
anorexia and
increased
interest in
eating
demonstrate
d normal skin
turgor
used
appropriate
imagery and
relaxation
before meals
consumed
diet high in
required
nutrients
carried out
oral hygiene
before meals

understanding of the
treatment plan for client.

appetite and increases

saliva production.

11. Instruct to monitor

weight of patient every
week and record it on a
weekly log.

9. Proper body position

and alignment are
necessary to aid chewing
and swallowing.
10. to enable the
independency in
implementation of it.
11. To have a baseline for
either development or
deviation from goal

3.Verbalized
understanding of
the need for
lifestyle
modifications of
patient
4.Demonstrated
progressive
weight gain
toward goal.

S: Hindi siya
nakakapagsalita
as verbalized by
the significant
other
O: PHYSICAL
EXAMINATION
Vital signs:
Temp: 36.7 C
36.7 C
PR: 68 bpm
RR: b19 cpm
BP: 120/80 mmHg
- (+) loss voice
-(+)tracheostomy

Impaired
Verbal
Communic
ation
related to
deficit
anatomy
and
physical
barriers
(tracheoto
my tube).

After 3-4 hours nursing

intervention the patient
will:
1. t be able to
identified other
communication
method.
2. PPerform nonverbal
communication
such as
touching and
physical
movement.
3. have
encouragement
and hope for
future.

1. Determine whether the

patient has other
communication disorders,
such as; hearing and
vision.
2. Provide appropriate
communication method of
choice for the patient's
needs such as boards and
pencils, alphabet boards or
pictures, and sign
language.
3. Allow sufficient time for
communication.
4. Give non-verbal
communication, for
example; touch and
physical movement.
5. Advise for constant
communication with the
outside world, for example;
newspapers, TV, radio and
calendar.
6. Tell a temporary loss of
speech after laryngectomy
partially, and or depending
on the availability of voice
aids.

1. Another problem
affecting the choice plan
for communication.

After the nursing

intervention the
client will:

2. Allows the patient to

express a need or
problem.

1. Used and
Identified other
communication
method such as
board and pencil.

3. Loss of speech and

stress disrupt
communications and
cause frustration and
obstacles expression,
especially when nurses
look too busy or working.
4. communicating
problems and meet the
needs of contact with
other people.
5. To maintain contact
with the pattern of a
normal life and continue
communication with other
ways.
6. Provide encouragement
and hope for the future by
thinking about the
meaning of choice and
speech communication.

2. Will not
experience
frustration and
stress.
3. Will maintain
normal life and
continue to
communicate
with others.
4. Will have
encouragement
and hope for the
future.

S: NURSING
HEALTH HISTORY
- 68 years old
male
- Lifestyle: smoker
& alcohol drinker,
occasionally.
- Radiation
therapy
O: PHYSICAL
EXAMINATION
Vital signs:
Temp: 36.7 C
36.7 C
PR: 68 bpm
RR: b19 cpm
BP: 120/80 mmHg
- (+)
tracheostomy,
midline, neck.
- Hoarse/slurred
speech
- Coherent,
oriented to time
person and place

Readiness
for
Enhanced
Coping

GOAL: After nursing

intervention, the client
will express feelings of
optimism about the
present.
OBJECTIVES:
NOC: Coping
After 2-3 hours of
nursing intervention the
patient will:
1. Reports decrease in
stress.
2. Uses behaviors to
reduce stress.

During nursing
intervention, the student
nurse will:
NIC: Coping Enhancement
1. Review extent of
feelings of anxiety.
2. Discuss indication and
method of treatment
3. Assess presence of
positive coping skills/inner
strengths e.g (use of
relaxation techniques,
willingness to express
feelings, use of support
systems).
4. Encourage patient to
talk about what is
happening at this time and
what has occurred to
precipitate feelings of
anxiety.
5. Evaluate ability to
understand events and
correct misconceptions by
providing factual
information.

1. There is a need to know

the extent of
disequilibrium and need
for intervention to prevent
or resolve the crisis.
2. Promotes active
participation of client in
therapeutic regimen.
3. R: Past coping skills
may be reused to relieve
tension and preserve
individual's sense of
control.
4. Provides clues to asses
patient to develop coping
and regain equilibrium.
5. Assists in the
identification and
correction of perception of
reality.

After nursing 2-3

hours of nursing
intervention, the
client will be able
to:
1. Consistently
report a decrease
in stress
2. Verbalize in
own words the
relevant
information
about treatment
3. Demonstrate
at 3 least
behaviors to
reduce stress
use of
relaxation
techniques,
willingness to
express feelings,
use of
support systems