Nursing Care plan. Name: Mr.Kedarsingh. Age: 45 years old. Diagnosis: Bladder cancer. Surgery: TURBT done on 29.12.

11 Acute pain related to surgical incision Risk for infection related to surgical incision open wound. Risk for impaired skin integrity related to problems in managing the urine collection appliance Disturbed body image related to urinary diversion Potential for sexual dysfunction related to structural and physiologic alterations Deficient knowledge about management of urinary function

Assessment Subjective data: Patient complains that he is having pain in surgical incision area, sharp, continuous, gradual, relieved after urinating. Pain was measured by graphical rating pain scale, it was found to be moderate pain. Objective data: Patients facial expression shows that he is in pain, Also his appetite is less due to the pain felt.

Nursing diagnosis

Nursing outcome

Planning *Observe or monitor signs and symptoms associated with pain, such as BP, heart rate, temperature, color and moisture of skin, restlessness, and ability to focus. * Anticipate need for pain relief. One can most effectively deal with pain by preventing it. * Respond immediately to complaint of pain.

Implementation *Vital signs were monitored

Rationale *Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating pain.

Evaluation The patient was well responding to the nursing interventions, after assessment and doing the nursing interventions the pain level on pain scale dropped from moderate to low pain, The patient is taking medication in time and is responding to the medications. The patient is comfortable now. Also his appetite has increased.

Acute pain Patient will have related to surgical Comfort Level and incision Patient will show Medication Response. And patient will be in less pain, his appetite will increase.

*Pain relief anticipation was assessed by asking

*To know the analgesic required

*Patient was attended * In the midst of when he had pain painful experiences a patients perception of time may become distorted. *Visiting hours were maintained, also environment was kept neat and clean, with less noise. * Patients may experience an exaggeration in pain or a decreased ability to tolerate painful stimuli if environmental,

* Eliminate additional stressors or sources of discomfort whenever possible.

intrapersonal, or intrapsychic factors are further stressing them. * Provide rest periods to facilitate comfort, sleep, and relaxation. * Give analgesics as ordered, evaluating effectiveness and observing for any signs and symptoms of untoward effects. * Whenever possible, reassure patient that pain is time-limited and that there is more than one approach to easing pain. *Teach the patient complementary therapy: Relaxation *The patient was told to rest for most of time * The patients experiences of pain may become exaggerated as the result of fatigue. * To reduce the pain.

*Pain medications were given to the patient. Tab. Voveron,50mg BD

*Patient was reassured with help of his family members.

*To reduce anxiety of patient.

* The patient was taught about relaxation method

*To reduce pain level.

Assessment Subjective data: The patient complained that he was having an surgical wound which was red in colour, and was having a discharge and was feeling pain at the site Objective data: The patient had surgical wound and was having discharge in the area

Nursing diagnosis Risk for infection related to surgical incision open wound.

Nursing outcome Patient will have reduced risk for infection after taking necessary precautions and carefully planning nursing interventions. And patient Remains free of infection, as evidenced by normal vital signs and absence of purulent drainage from wounds, incisions, and tubes.

Planning *Assess for presence, existence of, and history of risk factors such as open wounds and abrasions; indwelling catheters (Foley, peritoneal); wound drainage tubes * Monitor white blood count (WBC). Rising WBC indicates bodys efforts to combat pathogens; normal values: 4000 to 11,000 mm3. * Monitor the following for signs of infection: o Redness, swelling, increased pain, or purulent drainage at incisions, injured sites, exit sites of

Implementation Patient was assessed

Rationale *Each of these examples represents a break in the bodys normal first lines of defence.

Evaluation The patient after doing nursing interventions and providing teaching had less risk for infection at site of surgery, Patient understood how to take care of the wound, also was responding well to the nursing interventions.

*Patients blood was sent to laboratory for testing whole blood count.

* Monitor white blood count (WBC). Rising WBC indicates bodys efforts to combat pathogens; normal values: 4000 to 11,000 mm3. *To know if patient is at risk for infection or sepsis.

*Patient was monitored for the signs of infection

tubes, drains, or catheters * Assess nutritional status, including weight, history of weight loss, and serum albumin. *Patients nutritional * Patients with poor assessment was done. nutritional status may be allergic, or unable to muster a cellular immune response to pathogens and are therefore more susceptible to infection. *Patient was taught *To avoid risk for asepsis also asepsis infection. was maintained while doing procedures.

* Maintain or teach asepsis for dressing changes and wound care, catheter care and handling, and peripheral IV and central venous access management. *Wash hands and teach other caregivers to wash hands before contact with patient and between procedures with patient.

*Hand washing was done before starting contact with the patient.

*Washing between procedures reduces the risk of transmitting pathogens from one area of the body to another (e.g., perineal care or

central line care). Use of disposable gloves does not reduce the need for hand washing. * Limit visitors. *Visitors were limited, by allowing to come at specific time * This reduces the number of organisms in patients environment and restricts visitation by individuals with any type of infection to reduce the transmission of pathogens to the patient at risk for infection. * This maintains optimal nutritional status. * Fluids promote diluted urine and frequent emptying of bladder; reducing stasis of urine, in turn, reduces risk of bladder infection or urinary tract

* Encourage intake of protein- and calorie-rich foods. * Encourage fluid intake of 2000 ml to 3000 ml of water per day (unless contraindicated).

*Patient was given a diet plan.

*Patient was advised to increase fluid intake.

infection (UTI). *Administer or *Patient was given teach use of antimicrobial drugs. antimicrobial Inj. Ceftriaxone. (antibiotic) drugs as ordered. * Recommend the use of soft-bristled toothbrushes and stool softeners to protect mucous membranes. *Patient was recommended use of soft-bristled toothbrushes. * These agents are either toxic to the pathogen or retard the pathogens growth. *To reduce the risk of infection.

Assessment Subjective data: The patient complained that he is unable to maintain the urine collection pouch, which may cause injury to him

Nursing diagnosis Risk for impaired skin integrity related to problems in managing the urine collection appliance

Nursing outcome Patient will have reduced risk for impaired skin integrity

Planning

Implementation

Rationale *To know the skin integrity of patients skin

Evaluation

Objective data: The patient is having skin impairment and the pouch area, Needs to apply it correctly.

* Assess general *Patient was condition of skin. assessed. Healthy skin varies from individual to individual, but should have good turgor (an indication of moisture), feel warm and dry to the touch, be free of impairment (scratches, bruises, excoriation, rashes), and have quick capillary refill (<6 seconds). * Encourage ambulation if patient is able. *Patient was encouraged to ambulate

*To have good skin integrity and improved skin integrity. * To have skin intact and reduction in friction. * Hydrated skin is

* Clean, dry, and moisturize skin,

*Patient was instructed to keep skin clean and dry. *Patient was

* Encourage

adequate nutrition instructed to increase and hydration: intake of water. o 2000 to 3000 kcal/day (more if increased metabolic demands). o Fluid intake of 2000 ml/day unless medically restricted. *Teach patient proper application of the pouch, so that there will be avoidance of any injury in the part * Patient was taught the application.

less prone to breakdown. Patients with limited cardiovascular reserve may not be able to tolerate this much fluid.

*To maintain skin integrity