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Orif Post NCP

This nursing care plan is for a 6-year-old male patient who underwent open reduction internal fixation surgery on his left elbow. The plan identifies impaired skin integrity as a nursing diagnosis due to the post-surgical procedure. The goals are to establish rapport with the patient and family, assess vital signs, provide wound care education, and ensure the patient's vital signs remain normal after 1 hour of nursing intervention. The intervention included explaining dressing and drain care, keeping the area clean and dry, raising the bed rails, and teaching good hygiene principles. The family demonstrated understanding of proper post-surgical skin care and the patient's vital signs were stable after 1 hour.

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Kristine Young
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8K views1 page

Orif Post NCP

This nursing care plan is for a 6-year-old male patient who underwent open reduction internal fixation surgery on his left elbow. The plan identifies impaired skin integrity as a nursing diagnosis due to the post-surgical procedure. The goals are to establish rapport with the patient and family, assess vital signs, provide wound care education, and ensure the patient's vital signs remain normal after 1 hour of nursing intervention. The intervention included explaining dressing and drain care, keeping the area clean and dry, raising the bed rails, and teaching good hygiene principles. The family demonstrated understanding of proper post-surgical skin care and the patient's vital signs were stable after 1 hour.

Uploaded by

Kristine Young
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
  • Nursing Care Plan Overview

St.

Anthony’s College
San Jose, Antique
Nursing Department

Name of Patient: C.V.P.S. Operation Performed: Open Reduction Internal Fixation, Left Elbow
Age/Sex: 6/Male Perioperative Phase: Post-operative Phase

NURSING CARE PLAN

CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION


DIAGNOSIS

SUBJECTIVE: Impaired skin Impaired skin integrity GENERAL: INDEPENDENT: GENERAL:


integrity related to refers to the damage to
“May tahi run lima na,” post-surgical mucous membrane, After 1 hour of Establish rapport to the To gain the trust and After 1 hour of nursing
as verbalized by the procedure. corneal, integumentary,nursing intervention, patient. cooperation of the intervention, the goal was
patient’s mother. or subcutaneous the patient’s family patient. met. The patient’s family was
tissues. will be able to know, able to know, verbalize and
verbalize and Assess status and vital To obtain baseline demonstrate the right
OBJECTIVE: demonstrate the right signs. data. measures on taking care of
Reference: her post-surgical skin to
measures on taking
Vital signs taken: care of her post- Always keep the side To prevent patient prevent infection.
Retrieved from: rails up. from falling.
surgical skin to
BP - 100/80 mmHg https://nurseslabs.com
prevent infection.
T – 36.5°C Provide and explain To prevent infection SPECIFIC:
PR - 79 bpm dressing and drain care; and protect wound.
RR - 25 cpm SPECIFIC: keep the area clean and After 1 hour of nursing
Oxygen Saturation - 97% dry. intervention, the goal was
After 1 hour of met. The patient’s vital signs
nursing intervention, Teach the patient about Promote self-care and were still in its normal level
the patient’s vital the principles of good self-management to as evidenced by:
signs will still be in hygiene. prevent problem. BP of 100/70 mmhg
its normal level. T of 36.60C
PR of 78 bpm
RR of 24 cpm
Oxygen Saturation of 99%

Name of Students: Racquel V. Canono / Jonna Jane B. Tobias – BSN 4 Clinical Instructor: Jerry V. Able, RN, MAN

St. Anthony’s College San Jose, Antique Nursing Department Name of Patient: C.V.P.S. Operation Pe

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