St.

Anthony’s College
San Jose, Antique
Nursing Department

Name of Patient: C.V.P.S. Operation Performed: Open Reduction Internal Fixation, Left Elbow
Age/Sex: 6/Male Perioperative Phase: Post-operative Phase

NURSING CARE PLAN

CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

SUBJECTIVE: Impaired skin Impaired skin integrity GENERAL: INDEPENDENT: GENERAL:

integrity related to refers to the damage to
“May tahi run lima na,” post-surgical mucous membrane, After 1 hour of Establish rapport to the To gain the trust and After 1 hour of nursing
as verbalized by the procedure. corneal, integumentary,nursing intervention, patient. cooperation of the intervention, the goal was
patient’s mother. or subcutaneous the patient’s family patient. met. The patient’s family was
tissues. will be able to know, able to know, verbalize and
verbalize and Assess status and vital To obtain baseline demonstrate the right
OBJECTIVE: demonstrate the right signs. data. measures on taking care of
Reference: her post-surgical skin to
measures on taking
Vital signs taken: care of her post- Always keep the side To prevent patient prevent infection.
Retrieved from: rails up. from falling.
surgical skin to
BP - 100/80 mmHg https://nurseslabs.com
prevent infection.
T – 36.5°C Provide and explain To prevent infection SPECIFIC:
PR - 79 bpm dressing and drain care; and protect wound.
RR - 25 cpm SPECIFIC: keep the area clean and After 1 hour of nursing
Oxygen Saturation - 97% dry. intervention, the goal was
After 1 hour of met. The patient’s vital signs
nursing intervention, Teach the patient about Promote self-care and were still in its normal level
the patient’s vital the principles of good self-management to as evidenced by:
signs will still be in hygiene. prevent problem. BP of 100/70 mmhg
its normal level. T of 36.60C
PR of 78 bpm
RR of 24 cpm
Oxygen Saturation of 99%

Name of Students: Racquel V. Canono / Jonna Jane B. Tobias – BSN 4 Clinical Instructor: Jerry V. Able, RN, MAN