Veterinary Nursing Care Plan
Prepared by: [YOUR NAME]
Contact: [YOUR EMAIL]
Company: [YOUR COMPANY NAME]
Phone: [YOUR COMPANY NUMBER]
Website: [YOUR COMPANY WEBSITE]
Patient Information
Animal Name | Bella |
|---|
Species | Canine |
Breed | Golden Retriever |
Age | 5 years |
Sex | Female (Spayed) |
Owner Name | John Doe |
Admission Date | February 20, 2051 |
Discharge Date | February 23, 2051 |
Case: Post-Operative Care
Nursing Assessment
Surgical Procedure: Spay (Ovariohysterectomy)
Presenting Condition: Post-surgical pain, mild lethargy, reduced appetite.
Initial Findings: Incision site clean but inflamed, mild dehydration, reluctance to move.
Care Plan Goals
Manage pain effectively and maintain comfort.
Prevent infection and promote wound healing.
Ensure adequate hydration and nutrition.
Support mobility and reduce stress.
Nursing Interventions
Intervention | Frequency | Details | Assigned To | Evaluation Date |
|---|
Pain management | Every 6 hours | Administer prescribed painkillers (Meloxicam). | Veterinary Nurse | February 21, 2051 |
Wound care | Twice daily | Clean incision with antiseptic and monitor for signs of infection. | Veterinary Nurse | February 22, 2051 |
Hydration monitoring | Every 4 hours | Provide fresh water and offer small amounts of low-sodium broth. | Veterinary Technician | February 21, 2051 |
Nutrition encouragement | Twice daily | Feed recovery diet in small portions and record intake. | Veterinary Nurse | February 22, 2051 |
Mobility support | Twice daily | Assist in short, supervised walks to encourage circulation. | Veterinary Technician | February 22, 2051 |
Evaluation and Adjustments
Goal | Progress | Next Steps | Review Date |
|---|
Pain managed effectively | Moderate progress; mild discomfort | Continue medication, reassess on Feb 23. | February 22, 2051 |
Wound healing without infection | Positive progress; no redness | Maintain cleaning schedule. | February 23, 2051 |
Adequate hydration and nutrition | Good progress; appetite improving | Transition to regular diet post-discharge. | February 23, 2051 |
Mobility supported with reduced stress | Satisfactory; animal tolerates short walks | Increase walk duration gradually. | February 23, 2051 |
Additional Notes
Owner advised to monitor Bella for signs of discomfort or infection at home (e.g., swelling, excessive licking).
Follow-up appointment scheduled for March 1, 2051, to evaluate incision healing and overall recovery.
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