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NURSING CARE PLAN

Diagnosis: Avulsed Hacking Wounds secondary to Trauma

INTERVENTION
ASSESSMENT NURSING DIAGNOSIS PLANNING EVALUATION
ACTIONS RATIONALE
After 8 hours of  Assess signs and  Fever may indicate Goal met:
 “Medjo Risk for infection nursing symptoms of infection infection.
kinakabahan related to post- intervention especially temperature. Patient was free from
ako sat ahi operative patient will be any signs and
niya kasi Incision free from any symptoms of
bumubuka at signs and  Emphasize the  It serves as a first line of infections as
may symptoms of importance of defense against infection. manifested by
tumutulong infections as handwashing absence of fever.
tubig” as manifested by technique.
verbalized by absence of fever.
the patient’s  Maintain aseptic  Regular wound dressing
relative. technique when promotes fast healing and
changing drying of wounds.
 Intact suture dressing/caring wound.
lines noted on
the right  Keep area around  Wet area can be lodge area
temporal wound clean and dry. of bacteria
lobe.
 Emphasized necessity
 (+) discharge of taking antibiotics as  Premature discontinuation
noted ordered. of treatment when client
begins to feel well may
result in return of infection.

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