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    Surgical NCP

    Uploaded by

    Areeya Sushmita
    The document contains 3 patient records. The first patient, Mr. Valdez, had an exploratory laparotomy and was experiencing a fever. Nursing interventions included monitoring temperature, administering antipyretics and IV fluids, and providing cooling measures to lower the fever. The second patient, Mr. Jaudines, was at risk for infection due to broken skin. Nursing focused on education about hand washing and infection signs. The third patient record also describes Mr. Jaudines, who had skin impairment from an accident. Nursing interventions involved education, wound care, nutrition monitoring, and IV fluids to promote healing.

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    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd

    Surgical NCP

    Uploaded by

    Areeya Sushmita
    301 views6 pages
    The document contains 3 patient records. The first patient, Mr. Valdez, had an exploratory laparotomy and was experiencing a fever. Nursing interventions included monitoring temperature, administering antipyretics and IV fluids, and providing cooling measures to lower the fever. The second patient, Mr. Jaudines, was at risk for infection due to broken skin. Nursing focused on education about hand washing and infection signs. The third patient record also describes Mr. Jaudines, who had skin impairment from an accident. Nursing interventions involved education, wound care, nutrition monitoring, and IV fluids to promote healing.

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    Surgical Ncp

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    The document contains 3 patient records. The first patient, Mr. Valdez, had an exploratory laparotomy and was experiencing a fever. Nursing interventions included monitoring temperature, administering antipyretics and IV fluids, and providing cooling measures to lower the fever. The second patient, Mr. Jaudines, was at risk for infection due to broken skin. Nursing focused on education about hand washing and infection signs. The third patient record also describes Mr. Jaudines, who had skin impairment from an accident. Nursing interventions involved education, wound care, nutrition monitoring, and IV fluids to promote healing.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    301 views6 pages

    Surgical NCP

    Uploaded by

    Areeya Sushmita
    The document contains 3 patient records. The first patient, Mr. Valdez, had an exploratory laparotomy and was experiencing a fever. Nursing interventions included monitoring temperature, administering antipyretics and IV fluids, and providing cooling measures to lower the fever. The second patient, Mr. Jaudines, was at risk for infection due to broken skin. Nursing focused on education about hand washing and infection signs. The third patient record also describes Mr. Jaudines, who had skin impairment from an accident. Nursing interventions involved education, wound care, nutrition monitoring, and IV fluids to promote healing.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
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    You are on page 1of 6

    Patient: Mr. Valdez, R.

    Procedure Done: Exploratory Laparotomy

    Assessment

    Nsg. Diagnosis

    Plan

    Intervention

    Rationale

    Evaluation

    Subjective: masama pakiramdam ko, as verbalized by the patient

    Altered body temperature related to infection by increased body temperature, warm, and flushed skin.

    That the patient will maintain core temperature within normal range within the shift.

    INDEPENDENT:  Monitor core temperature.  To evaluate effects or degree of hyperthermia  To help lower the body temperature

    Objective:  Flushed skin; warm to touch  Vital signs taken as follows: Temp: 37.7 C RR: 22bpm PR: 83bpm

     Promote surface cooling by means of cool, tepid sponge baths  Administer replacement fluid and electrolytes

    Goal met. After hours of intervention, the patient was able to maintain the core temperature within normal range within the shift.

     To support circulating volume and tissue perfusion

     Maintain bedrest

     To reduce metabolic demands and oxygen consumption

    DEPENDENT:  Maintain IV fluids as ordered by the physician.  Administer antipyretic as ordered.  Administer antibiotic as ordered.  Prevents dehydration.

     Reduces fever.

     Treats underlying cause.

    Patient: Mr. Jaudines, D.

    Assessment

    Nsg. Diagnosis

    Plan

    Intervention

    Rationale

    Evaluation

    Objective:  Vital signs taken as follows: Temp: 37.7 C RR: 26bpm PR: 117bpm

    Risk for infection related to inadequate primary defenses as manifested by broken skin.

    That the patient will be able to verbalize understanding of causative or risk factors.

    INDEPENDENT:  Establish rapport.  To gain trust and cooperation of the patient.  To prevent cross contaminatio n and bacterial colonization.  To limit exposures, thus reducing cross contaminatio n.  To impart to patient when the wound become

    Goal is met. The patient was able to understand the causative or risk factors.

     Promote thorough hand washing by caregivers and patient.

     Monitor patients visitors and caregivers for respiratory illness.  Discuss to patients the following signs of

    infection redness, swelling, increased pain and fever.

    infected and when to sought medical care

    Patient: Mr. Jaudines

    Assessment

    Nsg. Diagnosis

    Plan

    Intervention

    Rationale

    Evaluation

    Subjective:

    Impaired Skin Inte grity related to sugat ko to nong skin destruction naaksidente ako secondary to as verbalized by vehicular accident. the patient. Objective: - redness noted - pain on the affected area with moist wound noted

    That the patient will be able to participate in prevention measures and treatment program.

    INDEPENDENT:  Establish rapport.  To gain trust and cooperation of the patient.  Health teachings regarding how to take care the impaired skin.  Do not position the client n site of impairment.  To educate the client.

     To protect the patient from advance effect of mechanical forces such as pressure, friction, and shears.  Inadequate nutrition intake places individuals at risk for skin breakdown

     Assess patients nutritional status.

    the

    and it compromise healing.  Monitor I and O.  Adequate hydration improves wound healing. Decreased urine output is a sign of dehydration.  An increased temperature can be a sign of infection.

     Monitor temperature.

    DEPENDENT:  Maintain IV fluids as ordered by the physician.  Administer medication (antibiotic) prescribed by the physician.  Prevents dehydration.

     To prevent infection.

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