Sample Nursing Care Plan for Uterine Prolapse (Post Operative)

Uterine Prolapse (Post Operative)

Assessment

Subjective Data:

• Pain in the area of operation.
• Tired.
• Dizzy.
• Nausea, bloating.

Objective Data :

• There is a wound in the groin.
• Fasting.
• Mucous membranes dry mouth.

Possible Nursing Diagnosis for Uterine Prolapse (Post Operative)

1. Acute pain related to the surgical wound.
2. Risk for fluid volume deficit related to vomiting after surgery.
3. Impaired skin integrity related to the surgical wound.
4. Risk for hypertermia related to surgical wound infection.
5. Knowledge deficit: surgical wound care related to lack of information.

Nursing Interventions for Uterine Prolapse (Post Operative)

1. Acute pain related to the surgical wound.

Goal: Pain disappeared after the act of nursing.
Expected outcomes:

• Pain is reduced gradually.

Interventions:

• Assess the patient's pain intensity.
• Observation of vital signs and patient complaints.
• Place the patient on a bed with a technique that is appropriate to the surgery performed.
• Give the sleeping position that is fun and safe.
• Instruct the patient to immediately move gradually.
• Give appropriate analgesic therapy medical program.
• Take action with the child nursing care.
• Teach relaxation techniques.

2. Risk for fluid volume deficit related to vomiting after surgery.

Goal: There is no shortage of fluid volume.
Expected outcomes:

• Elastic skin turgor, not dry,
• No nausea and vomiting.

Interventions:

• Observation of vital signs every 4 hours.
• Monitor the infusion.
• Give drink and eat gradually.
• Monitor for signs of dehydration.
• Monitor and record the fluid in and out.
• Measure body weight per day.
• Record and inform the doctor about vomiting.

3. Impaired skin integrity related to the surgical wound.

Goal: Damage to skin integrity is resolved.
Expected outcomes:

• The surgical wound is clean, dry, no swelling. no bleeding.

Interventions:

• Observation of the state of the surgical wound of signs of inflammation: fever, redness, swelling and discharge.
• Treat the wound with sterile technique.
• Keep around the surgical wound.
• Give nutritious foods and encourage patients to eat.
• Involve the family to keep the clan surgical wound environment.
• Teach family in the care of the surgical wound.

4. Risk for hypertermia related to surgical wound infection.

Goal: Hyperthermia is resolved.

Expected outcomes:

• The surgical wound is clean, dry, not swollen. no bleeding.
• The temperature in the normal range (36-37 ° C).

Interventions:

• Observation of vital signs every 4 hours.
• Give appropriate antibiotic therapy medical program.
• Give a warm compress.
• Monitor the infusion.
• Ambulatory surgical wound with sterile technique.
• Keep the surgical wound.
• Monitor and record the fluid in and out.

5. Knowledge deficit: surgical wound care related to lack of information.

Goal: The client knows how to take care of the surgical wound.

Expected outcomes:

• Parents understand the operation wound care.
• Parents can maintain cleanliness and surgical wound treatment.

Interventions:

• Teach parents how to care for the surgical wound and keep it clean.
• Discuss about the wishes of the family wanted to know.
• Allow the patient's family to ask.
• Explain about the care of patients at home, do not wet and dirty bandage.
• Suggest to continue treatment / take medication regularly at home, and control back to the doctor.

Evaluation

1. Obtain pain relief.
2. Patients receive adequate fluid intake volume.
3. Improved patient skin integrity.
4. Good skin turgor.
5. The client's body temperature within normal limits.
6. Gain knowledge about uterine prolapse and treatment program.
7. Mentions how the surgical wound care is good and right.