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Nursing Care Plan

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Putong, Jonathan 4 y/o Post incision and drainage Cues | Diagnosis | Inference | Plan of care | Nursing Interventions | Rationale | Evaluation | Subjective:“ sakit sugat ko dito ma” as verbalized by the patientObjective: * Localized erythema and edema * (+) pruritus on the site of the incision. * (+) Facial grimace * (+)Irritability * (+) Guarding behavior * (+) Crying * (+) VS normal T= 36.8 ‘ c PR= 77 RR= 25 * Pain assessment>Location: Right post auricular area>Interval: frequent | Acute pain related to tissue trauma secondary to incision and drainage as manifested by * Localized erythema and edema * Pruritus on the site of the incision * Facial grimace * Irritability * Crying * Guarding behavior * Frequent interval of pain | Nociceptive stimuli(wound/inflammation)↓Nerve fibers (nociceptor) ↓ ↓A-delta fiber C-fiber (fast) (slow) ↓ ↓ Spinal cord & Dorsal horn pain modulating circuit (primary touch fiber) Neospino- Paleospino- thalamic thalamic tract (sharp, tract (dull,bright pain) aching pain) Substantia Gelatinosa (synapse) Thalamus (center of awareness of pain) Cerebral Cortex (center of interpretation) Responses | After 6 hours of nursing interventions, the pain will be alleviatedAs evidenced by: * Pain occurrence can be felt intermittently & minimally. * Facial grimace ceased * Irritability & guarding behavior settled. * Episode of crying is diminished | Independent * Established rapport * Monitor vital signs * Inform client and his watcher about pain relief measures, including how long it takes to achieve relief and how long to expect relief to last. * Emphasize safety precaution measures to the patient and to the watchers * Encourage diversional activities such as slow, controlled deep breathing and coughing exercises. * Provided a quiet and comfortable environment. * Encourage the patient to take adequate sleep * Provide comfort measures such as change of position as possible. * Discuss to the patient and watcher the importance of intake of foods rich in Vit. C * Instruct the watcher and the patient regarding the importance of proper hygieneDependent * Administer pain reliever such as analgesics and antibiotics such as penicillin as prescribed by the physician. | * To gain trust and enhance the ability to participate in activities * Provide baseline data. Alterations from normal may be signs of infection. * Enhances trust and therapeutic relationship. * Providing information about precaution measures promotes safety * Alleviate pain and anxiety, promote relaxations. Decreased lung capacity and decreased cough efficiency are predisposing factors to respiratory infection. * Sustain a stress-free feeling to the patient and promotes effective coping to manage discomfort. * This promotes healing by reducing basal metabolic rate and allowing oxygen and nutrients to be utilized for tissue growth, healing and regeneration * Position changes promote comfort, reduce muscle tension and relieve pressure. * Foods rich in Vit. C promotes faster wound healing * Improper hygiene promotes the recurrence of infection * NSAID’s have an analgesic and anti inflammatory effect. Antibiotics are used to treat & prevent infections caused by susceptible pathogens in skin structure infections | Goal met:After 6 hours of nursing interventions, the pain was alleviatedAs evidenced by: * Pain occurrence can be felt intermittently and minimally * Facial grimaced ceased * Irritability & guarding behavior settled. * Episode of crying is diminished | Putong, Jonathan 4 y/o Post incision and drainage Cues | Diagnosis | Inference | Plan of care | Nursing Interventions | Rationale | Evaluation | Subjective:“ May tahi ako dito oh (post auricular area)” as verbalized by the patientObjective: * Disruption of skin surface at post auricular area * Incision is 5 mm in diameter * Localized erythema and edema * (+)Pruritus at the site of the incision * (+)pain * (+) VS normal T= 36.8 ‘ c PR= 77 RR= 25 | Impaired tissue integrity related to tissue trauma secondary to incision and drainage as manifested by * Disruption of skin surface at post auricular area * Incision of 5 mm in diameter * Localized erythema and edema * (+)Pruritus at the site of the incision * (+)pain | Mechanical or surgical Trauma(incision) Vascular Inflammatoryresponse responsePlatelets form a clot to stop bleedingfibrin meshworkPlasma is unable to flow in wounded areaOxygen and nutrients are not transportedReduced fibroblast functionUnable to synthesize collagen and granulation phaseIncrease tissue loadImpaired skin integrity | After 6 hours of nursing interventions, the patient will be able to display improvement in wound healingAs evidenced by: * Patient and the watcher verbalize understanding of condition and causative factors * Patient demonstrate behaviors or use of relaxation skills & diversional activities to promote healing and prevent complications * Patient display diminished pruritus in the incision site | Independent * Establish rapport * Monitor vital signs * Assess skin. Noted color,turgor and sensation. Describe and measured wound and observed changes. * Reinforce good skin hygiene to the patient and to the watcher e.g. wash thoroughly and pat dry carefully * Emphasize to the patient and watcher the safety precaution measures * Instruct to the patient and watcher the importance of proper hygiene * Accentuate the importance of adequate nutrition and fluid intake * Instruct the watcher to clip and file the nails of the client regularly * Provided a quiet and comfortable environment. * Encouraged coughing and deep breathing exercises. * Encouraged the patient to take adequate sleep.Dependent * Administer medications as prescribed by the physician. | * To gain trust and enhance the ability to participate in activities * Provide baseline data. * Establishes comparative baseline providing opportunity for timely intervention * Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin * Providing information about precaution measures promotes safety of the patient * Proper hygiene promotes faster wound healing because risk for infections are minimized * Improved hydration and nutrition, improved skin condition * Long and rough nail increases the risk of skin damage * Sustain a stress-free feeling to the patient and promotes effective coping. * Promotes relaxation to the patient * This promotes healing by reducing basal metabolic rate & allowing oxygen & nutrients to be utilized for tissue growth, healing & regeneration. * Using pharmacologic management in treating condition | Goal met:After 6 hours of nursing interventions, the patient was able to display improvement in wound healingAs evidenced by: * Patient and the watcher verbalized understanding of condition and causative factors as well as the watcher * Patient demonstrated behaviors or use of relaxation skills & diversional activities to promote healing and prevent complications * Patient displayed diminished pruritus in the incision site |

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