PROBLEM Status post VP shunting Incision at right sub coastal area

S dalawa yung sugat niya sa ulo, linagyan daw ng tubo para maalis yung tubig sa loob medyo namamaga nga ata eh as verbalized by patients significant The patient is others scheduled for VP shunting wherein the O incision site at excess CSF is right subcoastal area removed to decrease of head. intracranial pressure. - patient is lying on There are two blanket from their incision sites done at house the patients head - presence of thick (right subcoastal terminal hair around area). Excess incision sites cerebrospinal fluid is - inflammation at drained for palliative right side of head reasons. - rubor and callor around the wounded A break in the first part line of defense by the - WBC count is below body, the skin, would

EXPLANATION OF THE PROBLEM The patient is scheduled for VP shunting due to increased intracranial pressure and diagnosis of destructive hydrocephalus measuring 2.1 x 1.7 x 1.8 cm which are secondary to pituitary adenoma

NURSING CARE PLAN OBJECTIVE NURSING RATIONALE INTERVENTION LTO : after 3 days of Dx : Dx : Nursing Intervention 1.monitor vital 1. this would the client will be able signs determine if to prevent the risk there has been for infection systemic infection STO : occurring inside After 8 hours of the body nursing intervention, the client with the 2. Assess the 2. determine help of the significant patients patients ability others will be able knowledge about to perform to: condition. In independent 1. perform addition, the interventions independently significant others together with her proper wound knowledge since significant others care the patient may 2. take in be unable to do foods/diet that such because of would promote neurologic faster wound disturbances healing 3. identify 3. assess 3. determining the interventions that adequacy of blood supply for could prevent or blood supply and proper reduce the risk innervations of oxygenation of for infection the affected the tissues which 4. achieve timely tissue would aide in the wound healing, progress of free from signs of healing of the infection affected tissue

EVALUATION Criteria Result After 3 days of Nursing Intervention the client was able to prevent the risk for infection The client with the help of the significant others was able to: perform independen tly proper wound care take in foods/diet that would promote faster wound healing identify interventio ns that could prevent or

normal at 4.2 G/L (ref. value 5.010.0 G/L) - patient is having and IVF side drip of PLNSS 500ml + tramadol x 24 hours A Risk for Infection related to break in the skin integrity (right subcoastal area of head) secondary to status post VP shunt

promote the entrance of microorganisms which can cause infection at wound site or even sepsis through the bodys blood circulation if not treated properly

5. verbalize
feelings of understanding, recovery and comfort

4. assess
changes of wound site for depth, width, color, smell, location, temperature, texture, and discharges

4. Provides

comparative baseline for future assessment and promote timely nursing intervention and revision of care plan. It also determines the risk or degree of infection of the wound

5. obtain specific
tissue or specimen the wound

fluid from

5. determine is there is infection and provide information about nursing interventions to be planned and performed Tx : 1. promotes faster wound healing and prevent infection at the wound site 2. prevent accumulation of

reduce the risk for infection achieve timely wound healing, free from signs of infection verbaliz e feelings of understandi ng, recovery and comfort

Tx :

1. clean

the wound every shift or as required using povidone iodine

2. change dressings needed required

as or

exudates and proliferation of microorganisms on the dressing, preventing further infection 3. prevent dehydration and provide electrolytes and minerals needed by the body to recover

3. maintain adequate hydration by proper regulation of IVF and giving fluids as indicated 4. provide good nutrition by giving diet rich in protein and calories, and vitamins and/or minerals 5. promote early mobility by providing position changes, active or passive exercises and assistive

4. promotes

faster wound healing and provide the patient adequate source of energy for recovery

5. promote better

circulation at body parts and prevent excessive tissue pressure thus promoting faster wound healing and recovery

exercises

6. administer and monitor medication regimen like antibiotic and noting patients response Ed : Ed : 1. encourage patient to have adequate periods of rest and sleep

6. prevent infection determine effectiveness therapy presence of effects

and the of and side

1. save and restore energy for recovery

2. enable

2. teach the patient

and significant others how to do proper wound caring

client and significant others if the client cannot perform it, to do proper wound care independently that would promote faster wound healing and recovery

3. teach patient and

3. let the patient

and significant others appreciate the importance of wound caring

significant others the importance of proper wound

care

that would promote faster wound healing and recovery 4. let the patient appreciate the role of proper diet on his recovery and allow patient to continue his proper diet during his recovery

4. teach patient the importance of good nutrition during and after recovery

5. teach patient the importance of early mobility and exercises

5. let the patient

appreciate the importance of early mobility that would promote better circulation at body parts thus promoting faster would healing and recovery 6. provide the nurse a plan or revision of care appropriate for the patient and/or allow

6. encourage

verbalization of feelings and expectations regarding her

condition

nurse to determine needs of patient either spiritual, emotional and physiological