NOTRE DAME OF TACURONG COLLEGE

COLLEGE OF NURSING
NURSING CARE PLAN
NAME OF PATIENT: MR. EGGNOG
DIAGNOSIS: HYDROECELE INTRA-OPERATIVE
PHYSICIAN: DR. BREADSTICK
ASSESSMENT NEEDS NURSING GOAL/OBJ INTERVENTION RATIONALE EVALUATION
DIAGNOS ECTIVE
IS
SUBJECTIVE:
NUTRITIONA Excess GENERAL
L- Fluid : 1. Monitor - To monitor Goal partially
No verbal cues METABOLIC Volume After vital/cognitive signs, closely relevant met, patient was
PATTERN related to 8hours of watching for changes changes, any able to stabilize
the nursing in blood pressure, increase in fluid volume with
OBJECTIVE: BY: collection interventio heart & respiratory vital/cognitive minimal level.
-Enlarged both GORDON’S of fluid in n the rate. signs will report
side of his FUNCTIONAL the sac of patient will 2. Monitor Input and to physician.
scrotum HEALTH scrotum be able to Output. - This will
-Weak looking THROUGH as stabilize 3. Obtain patient measure the
-Awake evidence fluid history to ascertain the amount of fluid
-Initial V/S of: d by volume. probable cause of the loss & intake
Temp:36.8 enlargem fluid disturbance. - Which can
RR:21RPM ent of SPECIFIC: 4. Assess or instruct help to guide
PR84BPM scrotum. After 2- patient to monitor interventions.
BP:120/80 3hours of weight daily and May include
nursing consistently, with same increased fluids
interventio scale and preferably at or sodium
RATION n the the same time of day. intake, or
ALE: patient will 5. Evaluate urine compromised
Increase be able to: output in response to regulatory
d isotonic 1. diuretic therapy. mechanisms.
fluid Verbalize 6. Provide adequate - To facilitate
retention understand activity or position accurate
ing of changes as able. measurement
individual 7. Institute/instruct and to follow
dietary/ patient regarding fluid trends.
fluid restrictions as - Focus is on
restrictions appropriate. monitoring the
. response to the
2. diuretics, rather
Demonstra than the actual
te amount voided.
behaviors At home, it is
to monitor unrealistic to
fluid status expect patients
and reduce to measure
recurrence each void.
of fluid Therefore
excess. recording two
voids versus
six voids after a
diuretic
medication
may provide
more useful
information. N
OTE: Fluid
volume excess
in the abdomen
may interfere
with absorption
of oral diuretic
medications.
Medications
may need to be
given
intravenously
by a nurse in
the home or
outpatient
setting.
- To prevent
fluid
accumulation in
dependent
areas.
- To help
reduce
extracellular
volume. For
some patients,
fluids may
need to be
restricted to
10ml per day.
 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
NURSING CARE PLAN
NAME OF PATIENT: MR. EGGNOG
DIAGNOSIS: HYDROECELE
PHYSICIAN: DR. BREADSTICK
POST-OPERATIVE
ASSESSMENT NEEDS NURSING GOAL/OBJECTIVES INTERVENTION RATIONALE EVALUATION
3DIAGNOSIS

Cognitive Acute pain GENERAL: Independent:

SUBJECTIVE: perceptu related to After 8hours of 1. Monitor vital sign - Changes in VS Goal met as
Masakit ang al pattern tissue trauma nursing intervention q 4 and record. often indicate evidenced by
tahi sa my itlog secondary to the patient will be 2. Carefully assess acute pain and patients
ko” By: hydroecelecto able to report pain location of discomfort. verbalization
Gordon’ my as is relieved from 0 surgical - As this can of reduce
OBJECTIVE : s evidenced by out of 10 in pain procedure. influenced the pain felt from
Function pain scale of 5 scale. 3. Accept client amount of post the scale of
- weak looking al Health in scale of 10. description of op pain 4.
- facial Pattern Specific pain experience.
grimacing Objective: 4. Provide - Pain is
noted After 2-3hours of additional subjective
- Pain scale of nursing intervention comfort such as experienced
5 in scale of RATIONALE: patient will be able back rub. and cannot be
10. Due to the to: 5. Move patient felt by others.
- Restless tissue damage 1. Verbalized pain slowly and - Improves
- Uncomfortabl is reduced. deliberately, circulation,
brought by
e 2. Verbalized splinting painful reduce muscle
surgical
- incision on method that area. tension and
incision, pain 6. Maintain semi
his both side provides relief. anxiety
receptor send fowler position as
scrotum 3. Demonstrate use associated with
impulses to the of relaxation indicated. pain.
- Initial v/s of brain and back
T – 37.1oC skills. Dependent: - Reduce muscle
to the affected 4. Appear relaxed 1. Regulate IVF as tension/
BP – 120/90
mmHg part and that’s and able to have ordered. guarding, which
RR – 20cpm why patient feel rest and sleep. may help
PR – 75 bpm the pain. 5. Patient will 2. Administer minimize pain
manifest increase medication as of movement.
in comfort. indicated such as
analgesic; - Facilitate
narcotics. fluid/wound
3.Administer O2 as drainage by
indicated 2-3 liters gravity
reducing
diaphragmatic
irritation/
Abdominal
tension and
thereby
reducing pain.
- This provides
hydration and
main the fluid
and electrolyte
balance of the
patient.
- Reduce
metabolic rate
and intestinal
irritation from
circulating/local
toxin, which
aids in pain
relief and
promotes
healing.

- This will
maintain the
oxygen status of
the client and
supplement the
internal and
external
expiration of
different cell.
 NOTRE DAME OF TACURONG COLLEGE
COLLEGE OF NURSING
NURSING CARE PLAN
NAME OF PATIENT: MR. EGGNOG
DIAGNOSIS: HYDROECELE
PHYSICIAN: DR. BREADSTICK
POST-OPERATIVE
ASSESSMENT NEEDS NURSING GOAL/OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS S

ACTIVITY- Activity GENERAL: INDEPENDENT: -To

Subjective: EXERCISE Intolerance After 8hours of 1. Note pt. report determine Goal partially
Hindi ko pa PATTERN related to nursing of weakness, report of met as
masyado surgical intervention the fatigue, pain, complain felt evidenced by
kayang tumayo BY: procedure patient will be able difficulty in by pt. that PT can now
kasi wala pa GORDON’S secondary to to facilitate accomplishing have nurse maintain
masyado FUNCTION hydroecele as maintenance of task. the ability to regulatory
akong lakas. AL HEALTH evidenced by pt. regulatory 2. Monitor provide mechanic &
vital/cognitive managemen function but
THROUGH cannot able to mechanics &
signs, watching for t of care. only at
Objective: do his Activity of function.
changes in blood -To monitor minimal level.
-weak looking daily living. closely
pressure, heart &
-lying in bed SPECIFIC: respiratory rate. relevant
-awake RATIONALE: After 2-3hrs. of 3. Plan care with changes,
-irritable Insufficient nursing rest period any increase
-Initial V/S of; physiological or intervention patient between activities. in
T – 37.1oC psychological will be able to : 4. Provide positive vital/cognitiv
BP – 120/90 energy to -Identify negative atmosphere while e signs will
mmHg endure or factors affecting acknowledging report to
RR – 20cpm complete activity intolerance difficulty of the physician.
PR – 75 bpm required or & reduce their situation for the -To reduce
desired daily effects when client. fatigue.
activities. possible. 5. Encourage -Help to
-Used identified expression of minimize
techniques to feelings frustration &
enhance activity contributing rechannel
tolerance. to/resulting from energy.
-Participate condition.
willingly in 6. Promote comfort
necessary/desired measures -To enhance
activities. 7 provide for relief ability to
-Report pain. enhance to
measurable 8. Instruct client in participate in
increase in activity monitoring activities.
tolerance. response to activity -To ease the
-Demonstrate a and in recognizing fatigue of pt.
decrease in signs/symptoms. and feel
physiological signs 9. Encourage client relax.
& symptoms of to maintain positive -To endicate
intolerance. attitude, suggest need that
use of relaxation alter activity.
technique such as -To enhance
deep breathing sense of well
pattern. being.
10. Encourage pt. -To increase
to increase fluid energy
intake production &
increase
output
monitoring.
 PRIORITIZED PROBLEMS:

1. Excess Fluid Volume related to the collection of fluid in the sac of scrotum as evidenced by enlargement of
scrotum. (INTRA-OPERATIVE)

2. Activity Intolerance related to surgical procedure secondary to hydroecele as evidenced by pt. cannot able to do his
Activity of daily living. ( POST-OPERATIVE)

3. Acute pain related to tissue trauma secondary to hydroecelectomy as evidenced by pain scale of 5 in scale of 10.
(POST-OPERATIVE)

4. Disturbed Body Image related to the enlargement of his both scrotum as evidenced by patient verbalization
nahihiya ako sa mga kamag anak ko na malaman nila na ganito pala ang sakit ko”.( PRE-OPERATIVE)

5. Anxiety related to the surgical procedure as evidenced by patient verbalization “matakot ako operahan kasi baka
kung anu ang mangyari sa akin, baka mamatay pa ko”.( PRE-OPERATIVE)