[left]NURSING CARE PLAN
Medical Dx. right inguinal hernia
HEALTH HISTORY:
Admission chief complain and history of present illness:
Male patient 27 year old admitted to surgical ward in basma hospital from clinic. patient work in store and before three days ago patient was carry a heavy boxes, when he carry boxes he felt a sharp and sudden pain in inguinal area this lead to fall down the boxes .then when patient go to his home he felt this pain again when he carry television this lead patient to go to doctor yesterday then doctor was admit patient to hospital as case of right inguinal hernia and decide surgical to repair hernia.
History of past illnesses:
No chronic illness but patient left leg was broken before 13 year ago when he was play football. No past surgical or hospitalization
PHYSICAL EXAMINATION:
General appearance:
Pulse rate: 68 B/M Temperature: 37.2 cº
B.P: 125/80 R.R :16 /M
height : 172cm weight : 75kg
Pallor, fatigued and extremely ill
patient oriented to time place and persons
Respiratory System:
Respiratory rate: 15 Breath per minute
Respiratory rhythm: regular
No wheezing and no crackles
dry cough .no sputum
heart : no murmurs , normal s1,s2 sounds
renal system:
Normal urination pattern. no pain during urination, no past dropping ,no leg edema .
abdomen :
Normal color, no cyanosis, no accumulation fluid in abdomen, no umbilicus herniation, 5 cm surgical incision. no bleeding from surgical site , no discharge from surgical incision . Present of bowel sound.
Diagnostic test :
Nursing note Normal range Range Name Num
Normal
4.2-6.4 mmol/L 5 mmol/l Glucose 1
normal 4-11*10^3/m 9.6 WBC 5
Normal 4.5-6*10^6m 5.7 RBC 6
Normal 150-450*10M 249 PLT 8
Normal 135-148meq/l 144 Na 9
Normal 2-2.6mmol/l 2.4 Ca 10
Normal 3.-5.3meq/l 4.2 K 11
Medication
Note Side effect Dose Classification Action Name Num
Fever 750mg Antibiotic Maxil 1
Headache, dizziness 500mg/100ml Antibiotic Bactericidal: inhibits DNA synthesis flagyle 2
Diagnostic procedure: CBC , KFT , ECG .
Nursing Assessment:
Subjective data:
Patient said: I feel pain in surgical area in right side not radiate to left side relief by supine position increase by coughing, walking and setting (pain scale 6 from 10).
Patient said: I cannot move now freely without pain and I need assistance to get down from the bed.
Patient said: I do not know about the hernia
Objective data:
Pulse rate: 68 B/M Temperature: 37.2ºc
Pallor, fatigued and extremely ill
Respiratory rate:16 Breath per minute
Respiratory rhythm: regular breathing, conscious, Low level of knowledge about disease.
patient walk with assistance
Nursing Diagnoses:
Nursing Diagnoses 1:
Pain related to surgical procedure as manifested by patient verbalization.
Planning:
Goal: Relieving Pain Postoperatively
Ex. outcome: patient well verbalizes pain decreased from 6 to 3 on pain scale.
Nursing Interventions:
Have the patient splint the incision site with hand or pillow when coughing to lessen pain and protect site from increased intraabdominal pressure. Splinting and proper positing reduce the stress on the incision area.
Keep bedding clean, dry, and free of wrinkles and debris.
Provide therapeutic environment—proper temperature and humidity, ventilation, visitors.
Put patient in comfort position to decrease pressure on surgical incision
Explaining pain relief methods, such as Breathing exercises, heat application, and progressive relaxation because Breathing exercises and relaxation techniques decrease oxygen consumption, respiratory rate, heart rate, and muscle tension, which interrupt the cycle of pain–anxiety–muscle tension
Administer analgesics, as doctor ordered.
Evaluation:
· Goal met. patient now in general condition free from verbalization of pain and he said the scale of pain now is 3 from 10
Nursing Diagnoses 2:
Activity Intolerance related to limited mobility and weakness secondary to surgical incision and pain as manifested by patient verbalization and my observation.
Planning:
Goal: increasing Activity Tolerance
Ex. outcome: patient will be able to do daily activity without assistance
Nursing Interventions:
§ Encourage progress in the client activity level during my shift by:
- Allow the client legs to dangle first; support him from the side because dangling the legs helps minimize orthostatic hypotension.
- Increase the client time out of bed by 15 minutes each time. Allow him to set a comfortable rate of ambulation, to prevent overexertion.
- Encourage the client to increase activity when pain is at a minimum or after pain relief measures take effect.
· Take vital signs before activity, Repeat vital sign assessment after activity, and Assess for abnormal responses to increased activity. Because the Activity tolerance depends on the client ability to adapt to the physiological requirements of increased activity
Evaluation:
Goal partially met. Patient now do activity with less assistance
Nursing Diagnoses 3 :
Impaired Skin Integrity related to invasive procedure as manifested by surgical incision.
Planning:
Goal: Minimizing Complications of Skin Impairment
Ex. outcome: patient will be free from impairment skin integrity
Nursing Interventions:
· Perform hand washing before and after contact with patient to prevent contamination.
· Inspect dressings routinely and change it if necessary
· Record amount and type of wound drainage
· Turn the patient frequently and maintain good body alignment.
Evaluation:
Goal not met because wound healing need more than one shift care to maintain skin integrity
Nursing Diagnoses 4:
Knowledge deficit about disease and about wound care
Planning:
Goal: Educating the Patient
Ex. outcome: patient will have good knowledge about disease and about wound care
Nursing Interventions:
Encourage questions to answer about illness.
Describe illness and relate symptom of hernia.
Answer questions honestly and completely at appropriate level.
Teach patient how to care wound and how to promote healing.
Explain all procedure and treatment and the rational for them.
Teach patient about wound care and abut early sings of infection.
Evaluation:
Goal met
- Patient have good information about disease.
- all question has been answered .
- patient now have good information about wound care
Nursing Diagnoses 4:
Risk for Infection related to surgical incision
Planning:
Goal: Preventing Infection
Ex. outcome: patient will be free from sign and symptom of infection during my shift
.Nursing Interventions:
Check dressing for drainage and incision for redness and swelling.
Monitor for other signs/symptoms of infection: fever, chills, malaise, and diaphoresis.
Administer antibiotics as order
Evaluation:
Goal met: no signs or symptoms of infection on patient or around surgical incision during my shift
Comments recommendation:
Avoid carry any heavy thing
Take medication as doctor order on time
When any abnormal signs appear must be go to doctor not treat in home without doctor order.
Encourage regular health maintenance visits to clinic.[/left]
موضوع: NURSING CARE PLAN / HERNIA 
17/11/2009, 02:28
