NURSING CARE PLAN

POST-OPERATIVE CARE FOR DIRECT INGUINAL HERNIA

(Potential)

Assessment Nursing Objectives Interventions Rationale Evaluation

Diagnosis
Subjective Data Independent:

“Medyo masakit pa Risk for Be free of Assess the To evaluate Patient

rin po yung tahi ko bleeding active post-operative excessive maintains a
sa bandang kaliwa related to bleeding site for any bleeding normal blood
lalo na kapag surgical from the signs of active loss. count.
yuyuko ako, uubo at incision surgical bleeding.
magbubuhat , kahit site.
na magaan lang” Health Heavy Post-operative
(I feel slight pain in Sutured teaching on activities and site, dry and
my surgical suture area will be patient to pressure intact.
on the left side free from avoid from
especially when wound coughing and coughing
bending, coughing reopening. doing may
or even lifting a light strenuous developed
load weight) as activities. further
verbalize by a 57 laceration to
years old male the surgical
patient. site thus
basic
Patient mentioned procedures
that he cannot move must be
freely without pain discussed to
or discomfort in his lower the risk
left groin and needs of wound
assistance when reopening in
walking or sitting on performing
a chair. activities.

Patient also Apply cold Use of ice Patient didn’t

mentioned that he Surgical site pack to the bags to the develop any
often experience will be free surgical site surgical site post-operative
shallow breathing from may be used inflammation.
and keep him from swelling to prevent
coughing. swelling.

Objective Data
(+) Pain on the Dependent:
surgical site. Prepare to To promote No active
Patient administer clotting and bleeding and
Pain scale: 6/10 remains hemostatic diminish blood loss
free from agents. bleeding by severity from
(+) Facial grimace bleeding increasing the surgical
during movement of coagulation site.
the body. factors.
 Encourage To determine Fast recovery
Inguinal Incision: dry to engage patient for patient of the surgical
and intact patient in regular follow- management incision with
appropriate up issues the absence of
VS: BP 130/80 behaviors or requiring bleeding
mmhg, Temp 36.5 lifestyle monitoring
°C, PR 82 bpm, RR changes and/or
24 bpm, Oxy. Sat modification.
99%
Collaborative
:
Collaborate in
evaluating the
need for
replacing
blood loss
and be
prepared for
emergency
situation.

Confirm to
other
healthcare
provider if
patient needs
to take other
aspirin or
anticoagulant
s
 (ACTUAL)

ASSESSMENT NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective Data Independent:

“Medyo masakit Acute pain Verbalize Assess incision Determines Client displays
pa rin po yung tahi related to sense of pain and non- the needs improvement in
ko sa bandang surgical control of verbal signs of for the mood, coping.
kaliwa lalo na procedure as response to pain such as initiation of
kapag yuyuko manifested by acute lethargy, crying analgesic
ako, uubo at patient situation and and facing therapy. Client describes
magbubuhat , verbalization positive grimace. satisfactory
kahit na magaan outlook for the pain control at
lang” future Encourage Allays pain level less than 3
(I feel slight pain in adequate rest and to 4 on rating
my surgical suture periods to discomfort scale within 1 hr
on the left side prevent fatigue caused by of analgesic
especially when and maintain the incision. administration.
bending, coughing position of
or even lifting a comfort. Family
light load weight) Promotes members are
as verbalize by a understandi able to learn
57 years old male ng of non
patient. Dependent: treatments pharmacologica
Administer for pain l pain strategies
Patient mentioned analgesic post- to relieve
that he cannot appropriate for operative. client's pain.
move freely the severity of
without pain or pain and age. Client displays
discomfort in his improved well-
left groin and Identify specific being such as
needs assistance signs/symptoms relaxed muscle
when walking or and changes in tone and body
sitting on a chair. pain posture.
characteristics
Patient also requiring medical
mentioned that he follow-up. Client is no
often experience longer reported
shallow breathing any discomfort
and keep him from and irritation as
coughing. he moves.

Objective Data
(+) Pain on the
surgical site.

Pain scale: 6/10

Collaborative:
(+) Facial grimace Discuss with
during movement other family
of the body. member on the
causes of pain
 and intervention
needed to relieve
it.

Inguinal Incision:
dry and intact

VS: BP 130/80
mmhg, Temp 36.5
°C, PR 82 bpm,
RR 24 bpm, Oxy.
Sat 99%
 NURSING
CARE PLAN

Submitted by:

Claire B. Isip & Shiela Mae Nuñez

Submitted to:

Mrs. Valleros