Ncp Post Debridement

Assessment

Nursing Planning Intervention Diagnosis S: ³di ako masyado masyado Imbalanced After 8 hours of  v/s taken and makakaen´ as  Nutrition: Less nursing recorded verbalized by the pt. than body intervention the O: requirements r/t  pt will inadequate food verbalized I and O monitored Slightly Pale in intake understanding appearance the importance Encourage Decreased of proper  verbalization of  subcutaneous nutrition and feelings fats exercise Poor skin turgor  Kept safe and Weak in comfortable in bed appearance Limited imited ROM RO M Reinforced Lack of appetite adequate rest BP=100/70  period T=36.7 P=90 R=18 Referred to dietitian for further  assessment and recommendations regarding food  preferences and nutritional support y

y

Rationale *in order to get the baseline data

* Determination of  amount of  amount of  fluid   fluid  intake and output. *to know the  perception of client 

Evaluation y

y

y

y

y

y

*in order to avoid  accidents

y y

Facilitated proper   position while eating and observed SAP.

y

*to regain energy and to avoid   straining 

* Dietitians have a  greater  understanding of the nutritional value of   foods and may be helpful in assessing  assessing   specific ethnic or  cultural foods * Elevating the head  of bed 30 degrees

y

Patient verbalize understanding of  importance of   balance nutrition Demonstrates  behavior  changes to regain appropriate weight Able to ingest increase fluid intake and foods rich in vitamins. Able to consume Recommended Daily Allowances (RDA) Still pale in appearance, poor  skin torpor.

Provided good oral hygiene

Provide companionship during mealtime.

Encouraged to increase fluid intake at least 8 glasses of water a day and eat foods reach in protein, carbohydrates, and vitamins. Discourage  beverages that are caffeinated or  carbonated. Encouraged ambulation and  passive Rom

Health teaching rendered:

aids in swallowing  and reduces risk of  aspiration. *in order to give comfort to the  patient through feeling clean and fresh * Attention to the  social aspects of  eating is important  in both the hospital  and home settings. * Supplemental  nutrition, to enhance wound  healing and regain energy.

* These may decrease appetite and lead to early  satiety. * Metabolism and  utilization of  nutrients are enhanced by activity.

y

The basic four food groups, as well as the need for  specific minerals or  vitamins.

* Foods high in calories and protein that will promote weight gain and  nitrogen balance

Assessment

Nursing Diagnosis S:´masakit yung era ko Risk for  ´ as verbalized by the pt. infection r/t  post O: debridement Weak in appearance Poor muscle tone With wound dressing on left foot with elactic  bandage and soiled by pus y

y y

Planning

Intervention

Rationale

After 8 hours of  nursing intervention the pt will understand ways on  preventing infection and to reduce further  complication

v/s taken and recorded

*to get baseline data

Maintain clean technique in cleaning and changing the wound dressing.

*to avoid invasion of microorganisms

Instructed to perform *To promote  passive ROM  proper circulation Instructed client to limit visitors

Observed for any untoward s/sx such as redness, swelling, increased pain.

* This reduces the number of  organisms in  patient¶s environment and  restricts visitation by individuals with any type of  infection to reduce the transmission of   pathogens to the  patient at risk for  infection. *to assess the  signs of infection

Evaluation y

y

y

y

Patient verbalized understand ways on preventing infection and ways to reduce further  complication. Able to demonstrate  proper  colostomy care and hand washing Verbalized understanding the importance of proper  hygiene and identified s/sx of  infection. Still weak in appearance

Encourage intake of  *This maintains  protein- and calorieoptimal nutritional  rich foods.  status. *These measures Encourage coughing reduce stasis of  and deep breathing;  secretions in the consider use of  lungs and  incentive spirometer. bronchial tree. When stasis occurs, pathogens can cause upper  respiratory infections, including   pneumonia.

Health teaching given: Teach patient and significant others to wash hands often, especially after  toileting, y

*To lessen microorganisms;  Patients and  caregivers can  spread infection  from one part of  the body to another, as well as  pick up surface  pathogens; hand  washing reduces

 before meals, and before and after  administering self-care. y

y

Teach patient the signs and symptoms of  infection, and when to report these to the  physician or  nurse.

Reviewed importance of   proper  hygiene

these risks.

*To give immediate intervention

* To lessen microorganisms

CHRISTINE GRACE PONCIANO  BSN-III-C GROUP 15

SUBMITTED TO: MRS. CHRISTINE BELTRAN