nursing assesment

NURSING CARE PLAN FOR THE PATIENT: (ALLAN GARRY)# ASSESSMENT PLANNING IMPLEMENTATION EVALUATION1 Continuous Fever(380C) Goal:The fever (abnormal body temperature) shall be reduced to normal (36-370C) by 8:30am.Objective:I will cool sponge the patient and give a cup of cold water in a period of 30 minutes (8am – 8:30am).Rationale:To cure fever and reduce body temperature to normal Equipment:• Thermometer with tray and clean cotton swab• Pair of hand gloves• A bottle of cold water (and a cup)• Sponge/towel• Bowl (large dish) of water• Biro• Observation Sheet • Explain intension/what I will do and ask permission, wash hands, wear gloves and prepare equipment• Ensure the extra clothing is removed and the patient is in comfortable position for procedure. • Put cold water in the bowl and cold compress or cool sponge his body with the sponge and wipe him dry with towel• Give him a cup of cold water• Use the clinical thermometer (use clean swab to wipe it dry) and get his temperature (by placing the thermometer under his underarms). After 5 minutes remove the thermometer and Record his temperature on observation sheet.• Leave the patient comfortable and Report any abnormality After 30 minutes of nursing intervention, the patient’s body temperature has fallen to normal. The fever is reduced thus the goal was achieved.2 Severe ankle sore Goal: The ankle sore shall be cured by 8:30am of Day 5 (120 hours) of nursing care. Objectives:I will do wet-to-dry sore dressing procedure for the patient 6th hourly for five days. I will also give fruitsRationale:Protect sore from further injury/contamination; prevent flies touch & cross-infection, Promote wound healing & cure.Equipment:• Sterile tray containing • Bowl of swabs• Bowl for moist swabs• Normal saline (NaCl)• Large kidney dish for dressing – containing gauze swabs• pairs of forceps• 1 pair of scissors• Trash/bin with lid• Plaster/bandage• Dressing towel (if necessary) • Fruits – a piece pineapple, oranges, and fruit juices. • Greet the patient, and explain the procedure, ask permission.• Wash hands, collect required equipment, • Break open sterile tray and assemble equipment needed, and put patient at suitable position for procedure.• Use a forceps and remove old dressing & throw into the trash. Put the used forceps away.• Use other two forceps (holding one on each hand). Pick the moist swab and gently clean the sore (3-4 times) starting from the center and dispose the dirty swab. • By aseptic technique: Dress the sore carefully and correctly• Leave the patient comfortable with words of reassurance.• Wash the equipment, pack and send for sterilization. • Wash hands and give fruits • Report any abnormalities. The goal has been achieved. After the 120 hours (5 days) of nursing intervention, the patients sore shown great improvement and was finally cured. 3 Pustules between finger (scratches a lot) Goal: The pustules shall be cured by 72 hours (Day 3) of nursing intervention. Objective: I will wash, clean, and cold compress, and apply lotion on patient’s fingers (that is affected by pustule) every 4 hours for 3 days period.Rationale:To promote healing, prevent bad smell, prevent further spreading, and cureEquipment:• Bowl of lukewarm water• Pair of Gloves• Clinical lotion (calamine & iodine solution-2.5%)• sponge • gauze • 2 pair forceps• Clean forceps • Explain intension/what I will do and ask permission• wash hands, put on hand gloves and gather equipment• Put the patient in proper position for procedure• Soak the sponge in lukewarm water and gently wash fingers and compress the pustules between fingers 3-4 times.• Apply clinical lotion (iodine solution-2.5% and calamine) between affected fingers (this will rupture the pus and help relief itchiness), wrap the fingers with the gauze.• Leave the patient comfortable and report abnormal findings The goal was reached.After 72 hours of nursing intervention, the patient‘s pustule affected hand was cured.4 Looking Worried Goal: The patient shall be happy (not worried) by 12:00pmObjective:I will be talking to him, listening to him, and encouraging him at 30 minutes interval from 10:00am – 12:00pm.Rationale:To make the patient feel good/happy. This will aid his recovery.Things to Consider:• encouragement• recognition/acceptance• Emotional support • Attend to him politely and talk to him with smile.• listen attentively to what he has to say • comment and share hope • Giving encouragement• (e.g.. say things like ‘You will be fine)• Ask his guardian to always be there for/with him and talk with him.• Adults (nurse/guardian) understand and accept him as person.• Provide him with whatever he wants/need (food, clothes. Etc.)• Smile at him, talk, and listen to him with interest and express sympathy. The Goal was achieved.After 2 hours of nursing intervention, the patient looked happy.5 Not washed since admission to ward Goal:The patient will have showered – look clean and fresh by 1:30pmObjective:I will motivate the patient and assist the patient to have shower in 30 minutes (1:00pm – 1:30pm).Rationale:Improve patient’s cleanlinessEquipment:• Clean Towel• Soap• clean clothes• Pair of hand gloves • Use appropriate language (tok pidgin) to greet him, explain intention, and ask his permission.• Wear hand gloves and Prepare/collect equipment• Assist and escort patient to shower room (since he is ambulant) and help him have bath and wipe dry his skin with clean towel.• Give him new/clean clothes to wear• leave the patient comfortable and Report any abnormalities The goal was achieved.After 30 minutes of nursing intervention, the patient finally had shower and by 1:30pm he was wearing new/clean clothes and looks clean and fresh.