NURSING PROCESS CARE PLAN #2
Knowledge Deficit
PATIENT'S INITIALS:_______________
DATES OF CARE: _________________
ASSESSMENT
SUPPORTIVE
DATA
S: Pt asked if she was
allowed to shower with the
JP drain and central line in
place.
Pt’s mom stated that she
hadn’t taken a shower in 2
days b/c they weren’t sure.
Pt asked how to tape up the
Site and how to tell when
the bandages needed to be
changed.
O: __yoF
B/P 118/63
HR 85
RR 20
Ox3
2 days post op- JPDrain
placement- foul smelling
serosanguineous drainage
Central line placed in R
Upper Arm for TPN.
Lungs clear bil, ant/post
Hypoactive BS x4
Pt hair appears greasy.
DX: Peritonitis
Ruptured appdx
STUDENT'S NAME _________________________
ANALYSIS PLANNING IMPLEMENTATION EVALUATION
CLIENT GOALS/ SCIENTIFIC
NURSING OUTCOME NURSING PRINCIPLES/ OBSERVATIONS/
DIAGNOSIS CRITERIA ACTIONS RATIONALE CONCLUSIONS
Patient and family will 1.Inspect JP dressing, 1. Will act as a Pt and Mother wanted MC
Knowledge Deficit become more incision site, and Central baseline for further to take a shower. Supplies
knowledgeable regarding line and document teaching and for wrapping the site and
r/t the care and use of the findings. assessments. for shower were gathered.
JP drain and Central 2. Will allow comfort Provided privacy.
Care of Jackson Pratt Drain line. 2. Provide privacy to pt. and pt will be more
And Central Line for TPN Taught family the S&S of
open to teaching.
AEB infxn and skin quality.
3. Will allow pt and They verbalized that the
STG: 3. Will bring in supplies
family to site was without S&S of
1. Patient and mother and demonstrate how to
participate and ask infxn or skin break down.
will engage in wrapping wrap the JP drain,
questions about
of incision site to allow incision, and central line Showed pt where to cover
techniques.
pt to take a shower site. and how to dry off.
within 1 hour of request. Mother and Pt helped wrap
2. Patient will verbalize 4. Will teach pt and the sites.
signs of impaired skin family about S&S of 4. Will allow family
quality by eos. infxn to look out for. Daughter took shower and
and pt to be proactive
3. Patient will report 3 dried self off.
in Pt’s care and health.
S&S of infection at drain 5. Will offer self to be Post shower inspection,
and line site by eos. present for family and pt both dressings were still
to ask any questions they 5. Allows extra time dry and did not need to be
LTG: have about the JP drain for pt and family to changed.
1. Pt will help nurses or central line care for think about extra STG met and continuing
recognize when dressing them. information they need.
LTG Partially met and
changes need to be made continuing.
by discharge.