NURSING CARE PLAN
Medical Dx.: right
inguinal hernia
HEALTH HISTORY:
Admission chief complain and history of present illness:
Male patient 27 year old admitted to surgical ward in basma hospital from clinic .
patient work in store and before three days ago patient was carry a heavy boxes
,when he carry boxes he felt a sharp and sudden pain in inguinal area this lead to fall
down the boxes .then when patient go to his home he felt this pain again when he
carry television this lead patient to go to doctor yesterday then doctor was admit
patient to hospital as case of right inguinal hernia and decide surgical to repair hernia
.
History of past illnesses:
No chronic illness but patient left leg was broken before 13 year ago when he
was play football . no past surgical or hospitalization
PHYSICAL EXAMINATION:
0General appearance:
0Pulse rate: 68 B/M Temperature: 37.2 cº
1B.P: 125/80 R.R :16 /M
2height : 172cm weight : 75kg
3Pallor, fatigued and extremely ill
4patient oriented to time place and persons
1Respiratory System:
0Respiratory rate: 15 Breath per minute
1Respiratory rhythm: regular
2No wheezing and no crackles
3dry cough .no sputum
4heart : no murmurs , normal s1,s2 sounds
5renal system:
6normal urination pattern . no pain during urination, no
past dropping ,no leg edema .
7abdomen :
8 normal color , no cyanosis , no accumulation fluid in
abdomen , no umbilicus herniation , 5 cm surgical incision. no
bleeding from surgical site , no discharge from surgical
incision . present of bowel sound .
9Diagnostic test :
Num Name Range Normal range Nursing
note
1 Glucose 5 mmol/l 4.2-6.4 mmol/L Normal
5 WBC 9.6 4-11*10^3/m normal
6 RBC 5.7 4.5-6*10^6m Normal
8 PLT 249 150-450*10M Normal
9 Na 144 135-148meq/l Normal
10 Ca 2.4 2-2.6mmol/l Normal
11 K 4.2 3.-5.3meq/l Normal
Medication
Num Name Action Classification Dose Side effect Note
1 Maxil Antibiotic 750mg Fever Given
after
2 flagyle Bactericidal Antibiotic 500mg/100ml Headache, sensitivit
: inhibits y test
dizziness
DNA
synthesis
Nursing Assessment :
Subjective data:
Patient said : I feel pain in surgical area in right side not
radiate to left side relief by supine position increase by
coughing, walking and setting (pain scale 6 from 10 ).
Patient said : I cannot move now freely without pain and I
need assistance to get down from the bed .
Patient said : I don’t know about the hernia
Objective data:
0Pulse rate: 68 B/M Temperature: 37.2ºc
1Pallor, fatigued and extremely ill
2Respiratory rate:16 Breath per minute
3Respiratory rhythm: regular
breathing , conscious , Low level of
knowledge about disease . patient
walk with assistance
Nursing Diagnoses :
Nursing Diagnoses 1:
Pain related to surgical procedure as manifested by patient
verbalization .
Planning :
Goal : Relieving Pain Postoperatively
Ex. outcome : patient well verbalize pain decreased from 6 to 3
on pain scale.
Nursing Interventions :
Have the patient splint the incision site with hand or pillow when
coughing to lessen pain and protect site from increased intraabdominal
pressure. Splinting and proper positing reduce the stress on the
incision area.
Keep bedding clean, dry, and free of wrinkles and debris.
Provide therapeutic environment—proper temperature and humidity,
ventilation, visitors.
Put patient in comfort position to decrease pressure on surgical incision
Explaining pain relief methods, such as Breathing exercises, heat
application, and progressive relaxation because Breathing exercises
and relaxation techniques decrease oxygen consumption, respiratory
rate, heart rate, and muscle tension, which interrupt the cycle of pain–
anxiety–muscle tension
Administer analgesics, as doctor ordered.
Evaluation :
Goal met . patient now in general condition free from verbalization of pain and
he said the scale of pain now is 3 from 10
Nursing Diagnoses 2 :
Activity Intolerance related to limited mobility and weakness
secondary to surgical incision and pain as manifested by patient
verbalization and my observation .
Planning :
Goal : increasing Activity Tolerance
Ex. outcome : patient will be able to do daily activity without
assistance
Nursing Interventions :
Encourage progress in the client activity level during my shift by:
- Allow the client legs to dangle first; support him from the side
because Dangling the legs helps minimize orthostatic
hypotension.
- Increase the client time out of bed by 15 minutes each time.
Allow him to set a comfortable rate of ambulation, to prevent
overexertion.
- Encourage the client to increase activity when pain is at a
minimum or after pain relief measures take effect.
• Take vital signs before activity, Repeat vital sign assessment after
activity, and Assess for abnormal responses to increased activity.
Because the Activity tolerance depends on the client ability to
adapt to the physiological requirements of increased activity
Evaluation :
Goal partially met . patient now do activity with less assistance
Nursing Diagnoses 3 :
Impaired Skin Integrity related to invasive procedure as manifested
by surgical incision .
Planning :
Goal : Minimizing Complications of Skin Impairment
Ex. outcome : patient will be free from impairment skin integrity
Nursing Interventions :
• Perform hand washing before and after contact with patient
to prevent contamination .
• Inspect dressings routinely and change it if necessary
• Record amount and type of wound drainage
• Turn the patient frequently and maintain good body
alignment.
Evaluation :
Goal not met because wound healing need more than one shift care to maintain
skin integrity
Nursing Diagnoses 4 :
Knowledge deficit about disease and about wound care
Planning :
Goal : Educating the Patient
Ex. outcome : patient will have good knowledge about disease
and about wound care
Nursing Interventions :
Encourage questions to answer about illness .
Describe illness and relate symptom of hernia .
Answer questions honestly and completely at appropriate level .
Teach patient how to care wound and how to promote healing
Explain all procedure and treatment and the rational for them .
Teach patient about wound care and abut early sings of infection .
Evaluation :
Goal met
- Patient have good information about disease .
- all question has been answered .
- patient now have good information about wound care
Nursing Diagnoses 5 :
Risk for Infection related to surgical incision
Planning :
Goal : Preventing Infection
Ex. outcome : patient will be free from sign and symptom
of infection during my shift
.Nursing Interventions :
Check dressing for drainage and incision for redness and swelling.
Monitor for other signs/symptoms of infection: fever, chills, malaise,
diaphoresis.
Administer antibiotics as order
Evaluation :
Goal met : no signs or symptoms of infection on patient or
around surgical incision during my shift
Hani alzo3bi
