Nursing Care Plan
Student(s) Name: Date:
Medical Diagnosis:
| Assessment Data | Nursing Diagnosis and Related Goals | Nursing Interventions and Rationale | Evaluation |
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Objective Had Left TKA done this morning
bandage to left knee is bleeding through
VS:
BP 153/78
T 38.1
HR 108
RR 22
Sp02 98 percent on 4L via nasal prongs
Subjective
“I am cold and tired, I feel sick. I want to speak with my mother” |
Nursing diagnosis
Risk for infection related to fever, elevated heart rate and respiration rate, invasive procedure
Goal statment: Short- term Patient will demonstrate an understanding of ways to prevent the spread of infection and treat it by post op day 6. This will be evidenced by the patient ability to explain ways to prevent and trat an infection.
Long- term Patient will reduce the risk of infection, to prevent problems that may rise because of an infection this will be evidenced by restoration of normal vital signs. This will be completed by the patient discharge date.
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Nursing Interventions
1. Educate patient on the chain of infection and ways to prevent an infection. 2. Provide a summary of content that was taught. 3. Ask questions related to the education that was provided to the patient. 4. Monitor vital signs and WBC. 5. Regularly assess for signs of infection 6. Review medications
Rationale 1. Educating the patient will provide the patient the knowledge to demonstrate an understanding of ways to prevent the spread of infection and treat it. 2. This will help ensure that the client doesn’t forget the teaching, reinforcing memory. 3. This will allow to observe whether the patient truly understood the teaching. 4. Will help to monitor patient health and determine whether if there is an infection it is getting worse or better. 5. This will help confirm whether an infection as indeed formed. 6. Some medication may have an effect on the patients vital sign and results or affect the patient immune system. Reviewing the medication that the patient is currently taking can help restore vital sign to normal or in the case of infection prevent worsening. |
Short term – Met
Patient was educated about the chain of infection and ways to prevent an infection as well as the spread of it. This was verified when the patient said “The best way to prevent infections is to wash your hands”
Long term – Partially Met
Lab values where reviewed an increased in WBC count was noted. Healthcare workers are keeping a close eye on the vitals, any change of behaviour that may be noted from the patient, wound dressing and site. Physician is yet to be contacted to discuss possible review of medication due to absence from the office. |
References
NANDA International & Herdman, T. H. (2021-2023). NANDA International Nursing diagnoses: Definitions and classification 2012-14.
Wiley Blackwell.
Mayo Foundation for Medical Education and Research. (2022, December 15). High white blood cell count causes. Mayo Clinic. https://www.mayoclinic.org/symptoms/high-white-blood-cell-count/basics/causes/sym-20050611