Question Answered step-by-step Hello, I need help with the analysis data of this care plan…. Hello, I need help with the analysis data of this care plan. NURSING CARE PLAN NeedDataAnalysis (include references to support your findings) with rationale (Include subjective, objective data, diagnostic tests) Subjective: patient denies Nauseas/Vomit and pain. Objective: Vital signs: Temp:36.9, HR:17, BP:158/90, O2 Sat:96%room temperature, RR:17. Lab:Wbc :7.6RBC:4.12HGB: 126Hct: 0.378Platelet: 232Creatinine :65K+:3.4Na: 140Cl:180Anion Gap: 4 Diet: NPO.GI: Ileostomy, Abdominal surgical incisionUrinary Catheter. (Include subjective, objective data, diagnostic tests) Priority Nursing Diagnoses:Nursing Diagnosis (NANDA)Expected OutcomeNursing Interventions1.Activity intolerance relate to presence of abdominal surgical incision. While in my care, patient will be able to perform ADLs with minimal assistance.While in my care, patient will state the important of gradually increase activityAssess patient’s vital signs TID.Rationale: to obtained baseline measure and monitor change in vital signs resulting from a medical therapy (e.g., opioids).Assess signs and symptoms of orthostatic hypotension.Rationale: “patients who have experienced prolonged bed rest are at risk for orthostatic hypotension” (Potter et., 2019 p.560). It’s important to monitor hypotensive patients carefully to prevents fall. Assess for pain prior activities and administer pain medication PRN.Rationale: “Effective pain management will allow patients to participate in necessary activities such as ambulating” (Lewis et., p.427).Establish guideline and goals of activities with patient.Rationale: Motivation is enhanced if the patient participates in goals setting. Encourage adequate rest period especially before meals, ambulation, other ADLs.Rationale: Rest between activities provide time for energy conservation and recovery.Assess the need for ambulation aids (e.g., cane, walker) for ADLs.Rationale: Reduce risk for fall.Plan activities for times when patient have the most energy.Observe and document response to activity.Rationale: Close monitoring will serve as a guide for optimal progression of activity.2.Risk for Infection relate to Abdominal surgical incision. Surgery that involves a cut (incision) in the skin can lead to a wound infection after surgery. Surgical site infection (SSI) is a leading cause of adverse effects in surgical patients. Although it known that a person’s own skin flora can cause infections, SSI is currently the most common and costly healthcare-associated infection. At the end of my shift patient’s abdominal incision site will remain free from infection as evidence by: Vital signs within the normal range, urine output greater 30ml per hour and absence of signs and symptoms of wound infection Check vital signs TID Rationale: to obtained baseline measure and monitor change in vital signs specially temperature as indication of infection.Practice hand hygiene routinely before caring for a patient, between patients, and before any invasive procedures.Rationale: is the most important and most basic technique in preventing the transmission of infections (Potter et., p.700). Review orders for dressing change procedure. Be prepared to adjust dressing depending on wound progress.Rationale: Orders indicate type of dressing or applications to use; wounds change over time, so previous dressing may not be appropriate to current state of wound (Lewis et., p.1318). Assess surgical incision during the shift using the REEDA (redness, edema, ecchymosis, discharge, and approximation) method. Rationale: frequent assessment can detect signs and symptoms of possible infection. Maintain aseptic technique when changing dressing/caring wound.Rationale: Keep area around wound clean and dry.Rationale: wet can be lodge area of bacteria.Administer antibiotic as per doctor’s orders.Rationale:Antibiotics are medication used to treat bacterial infections.Provide urinary catheter care once during shift.Rationale: catheter care prevents access and limits bacterial ascent into, growth in, urinary tract.Monitor White cell count.Rationale: elevated WBC is typically an indication of infection. Health Science Science Nursing NURSING NURS2016 Share QuestionEmailCopy link Comments (0)
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