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PALAWAN STATE UNIVERSITY

College Of Nursing and Health Sciences


Puerto Princesa City

NURSING CARE PLAN

Name of Patient: Ms. Ann Sex: Female Age: 48 years old


Diagnosis: Diabetes mellitus foot/diabetes mellitus Attending Physician: Joseph M

ASSESSMENT NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION


DIAGNOSIS

At the end Assist the client To ensure At the end 1


of 1-2 hours in transferring safety hour of nursing
Subjective: Risk for fall Induction spinal of nursing intervention,
from during the
None r/t anesthesia intervention was able to:
wheelchair or transfer.
anesthesia , will able stretcher to the
effect to: Ensure the
-
OR table.
Objectives: Depress CNS safety of the
function - Ensure the patient from
Spinal safety of Position and OR tables and falling.
anesthesia the patient secure the arm boards - Provide safety
(Bupivacain from patient on OR are narrow, measures to
Decrease falling. placing prevent fall.
e 1 amp) table with
sensory - Provide patient at
given by the safety belt or
function safety risk for
anesthesiolo strains on
gist measures extremities as injury.
to prevent appropriate, Patient may
Numbness Numbness of fall. explaining become
of lower the lower necessity for resistive or
extremitie extremities restraint or combative
s
Unable to belt. when
move sedated or
lower Inform the emerging
extremitie patient how from
Unable to move
s narrow or wide anesthesia,
lower
the OR table is furthering
extremities
or let the potential for
patient touch injury.
the edge of the
bed.

Risk for fall Identify


environmental
hazard in the
To give
care setting
awareness
such as
to the
contraptions,
patient on
wirings/cable,
how narrow
IV stand, etc.
or wide the
Dont leave the OR table is.
patient
unattended
before, during Identification
and after of hazards
surgery. can
minimize
the
incidence of
fall.
To make sure
that the
patient is
secured.
PALAWAN STATE UNIVERSITY
College Of Nursing and Health Sciences
Puerto Princesa City

NURSING CARE PLAN

Name of Patient: Ms. Ann Sex: Female Age: 48 years old


Diagnosis: Diabetes mellitus foot/diabetes mellitus Attending Physician: Joseph M

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION


DIAGNOSIS

Anxiety At the end of 1- Provide Can provide At the end of 1-


2 hours of preoperative reassurance and 2 hours of
Subjective: nursing education. Discuss alleviate patients nursing
none intervention, the anticipated things anxiety, as well as intervention,
patient will able that may concern provide information the patient was
to: patient: OR lights, for formulating able to:
bovie pad, feel of intraoperative care.
Objectives: Acknowledge oxygen cannula. Acknowledges that Acknowledge
feelings and foreign feelings and
Facial tension identify identify
environment may
healthy ways be frightening, healthy ways
Restlessness
to deal with alleviates to deal with
Focus on self them. associated fears. them.
Appear relaxed Appear relaxed
or able to rest or able to
appropriately. rest
Report appropriately
decreased Validate source of Identification of .
fear and fear. Provide specific fear helps Report
accurate factual
anxiety information. patient deal decreased
reduced to realistically with it. fear and
manageable Patient may have anxiety
level. misinterpreted reduced to
preoperative manageable
information or have level.
misinformation
regarding surgery.
Fears regarding
previous
experiences of self
Note expressions of or family may be
distress and resolved.
feelings, of
helplessness, Patient may already
preoccupation, with be grieving for the
anticipated change loss represented by
or loss, choked the anticipated
feelings. surgical procedure,
diagnosis or
Tell patient prognosis of illness.
anticipating local or
spinal anesthesia This reduces concerns
that drowsiness and that patient may
sleep occurs, that see the
more sedation may procedure.
be requested and
will be given if
needed, and that
surgical drapes will
block view of the
operative field.
Prevent
unnecessary body
exposure during
transfer and in OR.
Patients are
concerned about
loss of dignity and
Give simple,
inability to
concise directions exercise control.
and explanations to
sedated patient.
Impairment of
thought process
Control external makes it difficult for
stimuli. patient to
understand lengthy
instructions.

Extraneous noises
and commotion
may accelerate
anxiety.
PALAWAN STATE UNIVERSITY
College Of Nursing and Health Sciences
Puerto Princesa City

NURSING CARE PLAN


Name of Patient: Ms. Ann Sex: Female Age: 48 years old
Diagnosis: Diabetes mellitus foot/diabetes mellitus Attending Physician: Joseph M

ASSESSMENT NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION


DIAGNOSIS

At the end of 1 Noted Used as baseline At the end of 1


hour of nursing preoperative, for monitoring hour of nursing
Subjective: Hypothermi Induction of interventions, intraoperative and postoperative interventions,
a r/t post anesthesia the patient will postoperative temperature. the patient was
nilalamig ako anesthesia able to: temperature. able to:
ga effect
Have an Have an
Objectives: Decreased
increased Assessed May assist in increased
bodys system
Exposure to body environmental maintaining or body
functioning
temperature, temperature and stabilizing temperature
cool
within modify as needed. patients with latest
environment
normal temperature. temp. of
(+) chills Decreased range Provided 36.1C
hypothalamus (36.5C- additional Heat losses (-) chills
Cold clammy control in 37.5C). blankets. occurs as skin (+) cold
skin thermoregulat Report (legs, arms, clammy skin
ion decreased head) is exposed
Initial chills. to cool
Temp.:35.5C Increased ambient environment.
room temperature Helps limit
Decreased in at conclusion of patients heat
body procedure. loss when drapes
temperature are removed and
is transferred to
PACU.
Continuously
Hypothermia
monitored the Monitors for
patient for the temperature
return of normal instability
physiological detection for
functioning, early
complications, and intervention.
re-warming.

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