NCP Multiple Stab wounds Group A PDF

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Summary

Nursing care plan on stab wounds...

Description

NURSING CARE PLAN #1 Assessment Subjective data: “magalisod ko gamay.” as verbalized by the patient. Objective data: v/s: RR-46cpm PR-84bpm BP-90/60mmhg T-36C  Use of accessory muscle to breathe  w/ stab wound laceration 5cm in left posterior axillary  w/ capillary refill of 4sec.

Nursing Diagnosis Impaired Breathing Pattern related to Acute pain

Planning SHORT TERM GOAL: After 4 hours of nursing intervention the patient will be able to display a effective breathing

Nursing Intervention 1. Monitor vital signs. 2. Check capillary refill and conjunctiva for paleness. 3. Elevated head of bed (semi-fowler’s position) 4.Encouraged position of comfort . 5. Encouraged slower/deeper respirations by using of pursed-lip technique, deep breathing exercises, splinting technique

Rationale 1. To have baseline data & for comparison. 2. To determine blood circulation. 3.To promote physiological/ Psychological ease of maximal inspiration. 4. to promote breathing pattern.

Evaluation SHORT TERM GOAL Goal Met At the end of nursing intervention the patient was able to display Effective breathing pattern

NURSING CARE PLAN #2 Assessment Subjective: No cues Objective: v/s RR-46cpm PR-84bpm BP-90/60mmhg T-36C  presence of stab wound right anterolateral thigh, right scapular area

Nursing Diagnosis

Planning

Risk for infection related to presence of stab wound right anterolateral thigh, right scapular area

SHORT TERM GOAL After 8 hours of nursing intervention, the client will be free from signs of infection as manifested by vital signs at normal range for his age esp. temperature. And absence of redness and draining of pus in the incision site.

Nursing Intervention 1Monitor vital signs Assess for signs and symptoms of infection specifically, temperature, draining of pus in incision and redness Emphasize the importance of handwashing Maintain aseptic technique when changing dressing and cleaning of wound. Keep area around wound clean and dry.

Administer antibiotics as prescribed. And emphasize the necessity of taking antibiotic as ordered

Rationale

Evaluation

Serve as baseline data, and may be used as indicator of infection

SHORT TERM GOAL After 8 hours of nursing intervention, the client was free from signs of infection as manifested by vital signs at normal range for his age esp. temperature of 36.6’C. And absence of redness and draining of pus in the incision site.

This signs may indicate infection It serves as universal precaution in infection control Regular wound dressing facilitates fast healing and drying of wound. Wet area can be lodge area of bacteria. Premature discontinuation of treatment when client begins to feel well may result in return of infection

NURSING CARE PLAN #3 Assessment Subjective: “mo action og sakit akong likod” as verbalized by the patient.  w/ pain scale of 6/10

Objective: v/s RR-46cpm PR-84bpm BP-90/60mmhg T-36C  w/ irritability

Nursing Diagnosis Acute Pain related to actual tissue damage.

Planning SHORT TERM GOAL After 4 hours of nursing intervention the patient will be able to verbalize pain is decreased from 8/10 to 3/10.

Nursing Intervention 1. Monitor vital signs.

2. Accept client’s description of pain and convey acceptance of client’s response to pain. 3. Provide comfort measures (touch, nurse’s presence) quiet environment, calm activities. 4. Encouraged use of relaxation technique such as deep breathing. DEPENDENT: 1. Administer analgesics (Ketorolac 30mg TIV) as ordered by the physician. to maximum dosage as needed,

Rationale 1. To have baseline data & to determine alteration of vital signs to its normal values. 2. To know the description of pain. 3. To promote nonpharmacological pain management. 4.To distract attention and reduce tension.

DEPENDENT: 1. To maintain acceptable level of pain. Notify physician if regimen is inadequate to meet pain control goal.

Evaluation SHORT TERM GOAL Goal Met At the end of nursing intervention the patient was able to verbalize pain is decreased from 6/10 to 4/10

NURSING CARE PLAN #4

Assessment Subjective: “” As verbalized by the patients friend. Objectives:  w/ stab wound laceration in the right anterolateral thigh, right scapular area

Nursing Diagnosis

Planning

“Impaired Physical mobility related to acute pain

SHORT TERM GOAL After 8 hours of nursing intervention relatives of the patient will verbalize understanding of situation and individual treatment regimen and safety measures.

Nursing Intervention

Rationale

1. Repositioned the patient every 2 hours.

1. To prevent pressure ulcer.

2. Supported affected body parts with pillows

2. To maintain position or function and reduce risk of pressure ulcers.

3. Provided safety measures like use of side rails.

3. To prevent fall that may cause injury.

4. Provided passive range of motion.

4. For good circulation.

5. Note emotional/behavioral response to problems of immobility.

5. To assess functional ability.

6. Encouraged participation in self care.

6. Enhances selfconcept and sense of independence.

DEPENDENT: 1.Administer medication prior to activity as needed by pain relief.

1.To permit maximal effort.

Evaluation

SHORT TERM GOAL

NURSING CARE PLAN #5 Assessment Subjective: No cues Objectives: v/s: RR-46cpm PR-84bpm BP-90/60mmhg T-36C  w/ stab wound right anterolateral thigh, right scapular area 

Nursing Diagnosis

Planning

“Impaired Tissue Integrity related to mechanical factor (stab wound on right anterolateral thigh, right scapular area.

LONG TERM GOAL After 3 days of nursing intervention, The patient will be able to display progressive improvement in wound healing, show absence of hemorrhage and signs of infection.

Nursing Intervention 1.

Inspect wounds for every shifts to note for any changes.

2.

Encouraged optimum nutrition w/ high quality protein, sufficient calories and vitamins

3.

Encouraged adequate periods of rest and sleep.

4.

Practice aseptic technique for cleansing /dressing/medicating the wound.

w/ wound dressing dry and intact

Discuss importance of early detection and reporting of changes or any unusual physical discomfort/changes in pain characteristics. Dependent:

Rationale 1. Promotes timely intervention and revision of plan of care 2. To optimize healing potential

3.To limit metabolic demands, maximize energy available for healing, and meet comfort needs. 4.Reduce risk of crosscontamination.

5.

Administer antibiotics (Mefenamic Acid 800mg) as ordered by the physician.

5.Promotes early intervention/reduces potential for complications.

To Relief pain, Headache, fever and soft tissue injury.

Evaluation LONG TERM GOAL...