NURSING CARE PLAN #1

Cues Nursing Objectives Intervention Rationale Evaluation

Diagnosis
Subjective: Risk for Short term: Independent: Independent Short term:
No data infection At the end of 8 hours 1. Demonstrate 1. To avoid Goal met. At the
related to of nursing and emphasize contamination end of 8 hours of
Objective: surgical interventions, the proper hygiene or spread of nursing
 RR: 24 incision patient will: and pathogens interventions, the
bpm a. Identify and handwashing. patient has
 PR: 118 demonstrate 2. Advise the 2. To avoid verbalized and
 BP: 90 interventions to watcher to spread of demonstrated
palpated prevent or keep the room pathogens understanding of
 Multiple reduce risk of and the bed of the necessary
abrasions infections the client clean interventions to
b. Demonstrate 3. Assess and 3. To check if promote wound
 Contusi
understanding of document skin there are signs healing and
ons
the significance condition, note of infection reduce the risk of
 Lacerati of handwashing inflammation infection such as
ons in the prevention and drainage. handwashing and
 Distend of infection 4. Monitor 4. Fever may proper hygiene,
ed c. Demonstrate temperature indicate showed no signs
abdomen proper q15 mins for infection of infection such
handwashing. the first 2 hours as increase in
d. Show no signs of then q4h after temperature and
infection. 5. Cleanse 5. To reduce WBC count
incision site per potential
Long term: facility protocol blood-stream Long term: 
At the end of 2 days while infections Goal met. At the
of nursing maintaining end of 2 days of
interventions, the aseptic nursing
patient will: technique. interventions, the
1. Not show any 6. Instruct to keep 6. Wet area can patient has
signs of the area be lodge area continually shown
 purulent around the of bacteria no signs of
drainage wound dry and infection such as
2. Continue clean. increased WBC
showing no 7. Educate client 7. To promote and temperature,
signs of the importance client absence of warm,
infection; the and how to independence red and infected
skin surface cleanse surgical incision
is not warm, incision site and properly
WBC is within and identify performed wound
normal range, signs of dressing while
no infection such practicing aseptic
inflammation as the type of technique.
is noted drainage,
a. Perform hotness and
wound redness of the 8. To facilitate
dressing skin surface. blood
aseptically 8. Encourage circulation and
early wound healing
ambulation.
Dependent:

Dependent:
1. Administer
medications
per doctors
order

Collaborative:
1. An increasing
Collaborative: WBC count
1. Assess and indicates the
monitor white body’s efforts
blood cell
 (WBC) count. to combat
2. Obtain sample pathogens.
of the drainage
and label 

CUES NURSING OBJECTIVES NSG INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Acute pain Short Term: Dependent: Dependent: Short Term:
No data related to stab At the end of 10 minutes  Monitor vital  To have a Goal met. After 10
wound to the of nursing interventions, signs baseline data minutes of nursing
Objective: upper left patient will be able to:  Keep at rest in  To lessen the interventions, patient
 RR: 24 quadrant adomen  Appear relaxed, semi-fowler’s pain. Gravity appear relaxed, was
bpm secondary to able to sleep/rest position localizes able to sleep/rest
 PR: 118 multiple appropriately  Provide comfort inflammatory appropriately.
 Stab abrasions, measures, quiet exudate into
wound to contusions, Long Term: environment and lower
the ULQ lacerations and At the end of 30 minutes calm activities abdomen or Long Term:
abdomen distended of nursing interventions,  Never apply heat pelvis, Goal met. After 30
 Multiple abdomen patient will be able to: to the surgical relieving minutes of nursing
abrasions  Report pain is incision abdominal interventions, patient
relieved/controlled  Watch closely for tension. was able to report that
 Contusi
possible surgical  Refocuses pain is
ons
complications attention, relieved/controlled
 Lacerati promotes
 Encourage
ons relaxation
verbalization of
 Distend feelings about and may
ed the pain such as enhance
abdomen concern about coping
tolerating pain,  This
anxiety, and increases the
pessimistic risk of
thoughts bleeding
 Continuing
 Identify ways of pain and
avoiding or fever may
minimizing pain signal an
(e.g., splinting abscess.
incision during  To evaluate
cough; using firm coping
mattress and abilities and
proper sup- to identify
porting shoes for areas of
low back pain; additional
good body concern
mechanics).
 timely
Independent: intervention
 Administer pain is more likely
medication as to be
per doctor’s successful in
order alleviating
pain.

Independent:
 Relief of pain
facilitates
cooperation
with other
therapeutic
interventions.