ncp post debridement

7/23/2019 Ncp Post Debridement

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Assessment Nursing

Diagnosis

Planning Intervention Rationale Evaluation

S: di ako masyadomakakaen asverbalized by the pt.

O:

y Slightly Pale inappearance

y Decreasedsubcutaneousfats

y Poor skin turgory Weak in

appearance

y Limited ROMy Lack of appetitey BP=100/70

T=36.7P=90

R=18

ImbalancedNutrition: Lessthan body

requirements r/tinadequate food

intake

After 8 hours ofnursingintervention the

pt willverbalized

understandingthe importance

of proper

nutrition andexercise

v/s taken andrecorded

I and O monitored

Encourage

verbalization of

feelings

Kept safe and

comfortable in bed

Reinforcedadequate rest

period

Referred to

dietitian for furtherassessment and

recommendationsregarding food

preferences andnutritional support

Facilitated proper

position whileeating and

observed SAP.

*in order to get thebaseline data

*Determination of

amountoffluidintake and output.

*to know the

perception of client

*in order to avoidaccidents

*to regain energyand to avoid

straining

*Dietitians have a

greaterunderstanding of the

nutritional value offoods and may be

helpful in assessingspecific ethnic or

cultural foods

*Elevating the headof bed 30 degrees

y Patient verbalizeunderstanding of

importance ofbalance nutrition

y Demonstratesbehaviorchanges to

regainappropriate

weight

y Able to ingestincrease fluid

intake and foodsrich in vitamins.

y Able to consumeRecommendedDaily

Allowances(RDA)

y Still pale inappearance, poorskin torpor.


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Provided good oral

hygiene

Provide

companionshipduring mealtime.

Encouraged to

increase fluidintake at least 8

glasses of water aday and eat foods

reach in protein,carbohydrates, andvitamins.

Discourage

beverages that arecaffeinated or

carbonated.

Encouragedambulation and

passive Rom

Health teaching

rendered:

aids in swallowing

and reduces risk of

aspiration.*in order to givecomfort to the

patient throughfeeling clean and

fresh*Attention to the

social aspects of

eating is importantin both the hospitaland home settings.

* Supplementalnutrition, to

enhance woundhealing and regain

energy.

* These maydecrease appetite

and lead to early

satiety.

*Metabolism and

utilization ofnutrients are

enhanced byactivity.


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y The basicfour food

groups, aswell as the

need forspecific

minerals orvitamins.

*Foods high in

calories and proteinthat will promoteweight gain and

nitrogen balance


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Assessment Nursing

Diagnosis

Planning Intervention Rationale Evaluation

S:masakit yung era ko as verbalized by the pt.

O:

y Weak inappearance

y Poor muscle toney With wound

dressing on leftfoot with elactic

bandage andsoiled by pus

Risk forinfection r/tpost

debridement

After 8 hours ofnursingintervention the pt

will understandways on

preventinginfection and to

reduce further

complication

v/s taken andrecorded

Maintain cleantechnique in cleaning

and changing thewound dressing.

Instructed to performpassive ROM

Instructed client tolimit visitors

Observed for anyuntoward s/sx such

as redness, swelling,increased pain.

*to get baselinedata

*to avoid invasionof microorganisms

*To promoteproper circulation

* This reduces the

number oforganisms in

patientsenvironment and

restricts visitationby individuals with

any type ofinfection to reduce

the transmission ofpathogens to the

patient at risk forinfection.

*to assess the

signs of infection

y Patientverbalized

understand wayson preventing

infection andways to reduce

furthercomplication.

y Able todemonstrateproper

colostomy careand hand

washing

y Verbalizedunderstandingthe importanceof proper

hygiene andidentified s/sx of

infection.

y Still weak inappearance


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Encourage intake of

protein- and calorie-rich foods.

Encourage coughing

and deep breathing;consider use ofincentive spirometer.

Health teachinggiven:

y Teach patientandsignificantothers to

wash handsoften,

especiallyafter

toileting,

*This maintains

optimal nutritionalstatus.

*These measures

reduce stasis of

secretions in thelungs andbronchial tree.

When stasisoccurs, pathogens

can cause upperrespiratory

infections,includingpneumonia.

*To lessenmicroorganisms;

Patients andcaregivers can

spread infectionfrom one part of

the body toanother, as well as

pick up surfacepathogens; hand

washing reduces


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before meals,

and before

and afteradministeringself-care.

y Teach patientthe signs and

symptoms ofinfection, and

when toreport these

to thephysician or

nurse.

y Reviewedimportance of

properhygiene

these risks.

*To giveimmediate

intervention

* To lessen

microorganisms


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CHRISTINE GRACE PONCIANO

BSN-III-CGROUP 15 SUBMITTED TO:

MRS. CHRISTINE BELTRAN

ncp post debridement

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