Question

nursing care plan for case study chapter 57

Answer 1

Case study chapter 57 contains management of a female patient having female reproductive disorder.

suppose, Namita Mondal, a patient of 47years old suffering from Menorrhagia due to fibroid uterus, has recent hysterectomy. The nursing care plan of the patient will be-

1. Nursing Assessment:

Subjective data: The patient complain that she is suffering from pain in lower abdomen.

Objective data: Assessing pain scale.

•Nursing Diagnosis: Acute pain related to surgical incision as evidenced by patient's facial expression.

•Goal: To reduce pain.

•Planning

•Pain level should be assessed.( Duration, frequency, severity)

•Calm and quite environment should be provided.

•Comfortable position should be given.

Analgesic should be given as per doctor's order.

•Intervention

• Pain level is assessed to know baseline data.

• Calm and quite environment is given to make comfortable the patient.

•Comfortable position is given to the patient.

•Analgesic is given as per doctor's order.( Inj PCM)

Evaluation: pain level is reduced to some extent.

2. Nursing Assessment:

Subject data: patient complain that she can't maintain personal hygiene.

Objective data: physical assessment.

• Diagnosis: Activity intolerance related to surgical incision as evidenced by patient's vernalization and physical assessment.

• Goal- To improve daily activity level.

Planning:

•patient's activity level should be assessed.

•patient should be assisted to perform daily living activities.

•Basic care should be given to the patient.( eye care, mouth care)

•Feeding should be provided.

Intervention:

•patient's activity level is assessed.

•Patient is assisted to perform daily living activities.

Basic care is given.

Feeding is provided through rule's tube.

Evaluation: Activity level is improved to some extent.

3. Nursing Assessment.

Subjective data: Nil (as patient can't asses the infection level by ownself.)

Objective data: Presence of surgical incision.

• Diagnosis- Risk for infection related to surgical incision.

•Goal- To reduce risk for infection.

Planning

•Surgical incision site should be assessed for sign of infection.( Redness, discharge, swelling)

• Vital signs should be checked for determine fever.

• Hand washing should be done before and after doing any procedure.

• Aseptic technique should be maintained during invasive procedures.

Antibiotics should be administered as per doctor's order.

Intervention:

• surgical incision site is assessed.

Handwashing is done.

Aseptic technique is maintained.

Antibiotic is administered.

Evaluation: Risk for infection is reduced to some extent.