NURSING CARE PLAN

SORIANO, Angelica Joan M.

NCM 114

INSTRUCTION:
Scenario 1: The Older Adult recovering from Prostate Surgery.
Nursing Diagnosis: Risk for Injury and Infection related to surgery.
GOAL NURSING ACTIONS
 Assess the general status of the
client in order to determine the
client’s condition that may cause
injury and infection.
 Assess mood coping abilities,
personality style that may result in
carelessness in order to determine
the level of cooperation.
The client will verbalize understanding of
 Assess environmental factors that
factors that may contribute to possible
may lead to injury and infection in
injury and infection.
order to determine the underlying
causes.
 Promoting client’s safety by
monitoring V/S, and providing
materials for injury prevention in
order to lessen the risk for injury,
safe environment and promote
client’s comfort.
 Maintain side rails up in order to
prevent potential injury of the
patient.
 Place assistive devices within
reach in order to prevent errors in
occurring that may result to
injury.
The patient client will be able to  Note the patient’s level of
demonstrate precautions in the risk cognition and competence to
factors contributing to injury. evaluate the patient’s ability to
protect self.
 Assess patient’s muscle strength
and motor coordination in order to
identify risk of injury.
 Monitor environment potential
unsafe conditions to assess
potential hazard to the patient.
 Encourage high fluid intake
The patient will be able to change unless contraindicated.
behaviors to reduce risk factors from  Advise the patient to prevent
injury and infection. constipation.
 Recommend dietary adjustments
 as needed.
 Advise the patient to avoid
strenuous activities for 3 to 4
weeks.
 Advise the patient to consult with
the physician regarding the use of
stool softener if bowel movements
are stained or irregular.
 Teach the patient to observe for
and promptly report signs of
complications, including bright
red blood in urine, elevated
temperature, severe pain, and
weakness.
 Establish rapport in order to make
an efficient nurse-patient
communication.
 Carefully monitor the patient’s
vital signs in order to have a
baseline data about the present
status of the patient.
The patient will be able to maintain vital  Administer medication regimen as
signs within normal range, identify and ordered by the physician to
verbalize interventions that will reduce determine the effectiveness of the
the risk for infection. regimen to the patient.
 Emphasize the necessity of taking
antibiotics as directed by the
physician to prevent infection.
 Instruct the patient in techniques
to care for lesion and prevention
of spread of infection in order to
promote prevention of infection.
Patient is free from any signs and  Assess signs and symptoms of
symptoms of infections. infection especially temperature
as fever may indicate infection.
 Emphasize the importance of
handwashing technique as it
serves as a first line of defense
against infection.
 Maintain aseptic technique when
changing dressing/caring wound
as regular wound dressing
promotes fast healing and drying
of wounds.
 Keep area around wound clean
and dry as wet area can be lodge
area of bacteria.
 Emphasize necessity of taking
antibiotics as ordered because
premature discontinuation of
 treatment when patient begins to
feel well may result in return of
infection.

Scenario 2: Nursing Diagnoses: (1) Sexual Dysfunction related to surgery; (2)

Deficient knowledge related to the effect of surgery on sexual function.
GOAL NURSING ACTIONS
 Discuss with the patient’s
significant other the potential risk
for anxiety and other psycho-
logical factors related to illness
and surgery to interfere with
sexual dysfunction.
 Encourage the patient to share
other forms of intimacy until
intercourse can be resumed to his/
her partner.
 Consult with the physician and
discuss with the patient regarding
The patient expresses a rational view of sexual restrictions.
the effect of surgery on sexual activity.  Assess the patient’s understanding
of the impact of surgery on sexual
function.
 Clarify misinformation as needed.
 Listen to the patient’s concerns
and provide support.
 Discuss anticipated return of
sexual function with the patient’s
significant other, if acceptable to
the patient.
 Prepare the patient for possibility
of retrograde ejaculation which
will make urine appear milky.
The patient will verbalize understanding  Obtain sexual history including
of individual reasons for sexual problems. usual patterns of functioning and
level of desires in order to
maximize communication and
understanding,
 Identify current stressors in
individual situations.
 Avoid making value judgments.
 Establish therapeutic nurse-patient
relationship.
 Discuss with the couple the
potential for anxiety and other
psycho-logical factors related to
illness and surgery to interfere
with sexual function.
 Encourage the couple to share
other forms of intimacy until
 intercourse can be resumed.
 Help patient to determine time
dimension associated with the
onset of the problem and discuss
what was happening in his or her
life situation at that time.
 Encourage the patient to discuss
disease process that may be
contributing to sexual
dysfunction.
 Ensure that the patient is aware
that alternative methods of
The patient will resume sexual activity at achieving sexual satisfaction exist
level satisfactory to self and partner. and can be learned through sex
counseling if he or she and partner
desire to do so.
 Observe client behaviors and the
responses he or she elicits from
others.
 Give social attention (e.g., smile,
nod) to desired behaviors.
 Note cultural, social, ethnic,
racial, and religious factors that
may contribute to conflicts
regarding variant sexual practices.
 Determine stressors and discuss to
the patient what is happening in
his or her life situation.
 Encourage the patient to discuss
the disease process.
The patient will express satisfaction with  Note and identify factors that
own sexuality pattern. affect client’s sexuality.
 Be accepting and nonjudgmental
because sexuality is a very
personal and sensitive subject.
 Provide positive reinforcement to
motivate the patient.

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Applications.Manila. APD Educational Publishing House.
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6. https://nurseslabs.com/risk-for-falls/
7. https://www.scribd.com/doc/48492494/NCP-SEXUAL-DISFUNCTION
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cancer.html
9. https://nurseslabs.com/sexual-dysfunctions-paraphilias-and-gender-
dysphoria/#nursing_care_planning_and_goals