Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNIG INTERVE EVALUATION

NTION

S : Namamaga Impaired skin SHORT INDEPEND After 4 hours of

at namumula ang integrity related TERM GOAL ENT : rendering
kanang paa ko. to bacterial : >Identify To assess nursing
As verbalized by infection as After 4 hours underlying causative/cont intervention, the
the patinet. manifested by of rendering cause/condit ributing clients mother
the swelling of nursing ion factors. participated in
O: the right foot. intervention, involved. preventive
-swelling of the patient will be measures and
right foot able to >Note To assess treatment
-skin redness participate in changes in extent of programs for her
-skin lesions preventive skin color, involvement/i child.
measures and texture and njury.
treatment turgor.
program.

LONG TERM >Determine To assess

GOAL: depth of extent of
injury/dama involvement/i After week of
After 1 week ge to njury. teaching the
the client will integumenta client, he is seen
be taught what ry system. doing a self-
a part of his inspection of his
body is at most >Inspect To assist with lower
risk for skin skin on a correcting/min extremities.
break down daily basis, imizing
describing condition and
lesions and promote
changes optimal
observed. healing.

>Keep the To assist

area bodys natural
clean/dry, process of
prevent repair.
infection,
and
stimulate
circulation
to
surrounding
areas.

>Review To promote
importance wellness.
of skin and
 measures to
maintain
proper skin
functioning.

>Discuss
importance To promote
of early wellness.
detection of
skin
changes
and/or
complicatio
ns.
.
DEPEDEN
T:
>Assist To relieve
Nurse on inflammation.
duty in give
prescribed
IV meds as
indicated.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S : Medyo ni- Fear related to After 8 hours INDEPENDENT : After 8 hours of

nerbyos na ako unfamiliarity of rendering >Note degree of To assess rendering nursing
ng makausap ko with nursing incapacitation. degree of fear intervention,
ang doctor. As environmental intervention, and reality of clients fear has
verbalized by experiences as the client will threat lessened.
the patient. evidenced by lessen his perceived by
increased fear. the client.
-increased alertness.
alertness >Measure vital To assess
-v/s taken as signs/physiological degree of fear
follows : responses to situation. and reality of
P : 125 bpm threat
R : 22 cpm perceived by
the client.
>Stay with the client or Sense of
make arrangements to abandonment
have someone else be can exacerbate
there. fear.

>Identify clients Enhances

partner the sense of
responsibility for the control
solutions.

>Instruct patient in use Provides a

of helpful and
relaxation/visualization healthy outlet
and guided imagery for energy
skills. generated by
fearful
feelings and
promotes
relaxation.
ASSESSMENT DIAGNOSIS PLANNIG INTERVENTION EVALUATION

S : Namamaga Impaired skin SHORT INDEPENDENT : After 4 hours of

at namumula ang integrity related TERM GOAL >Identify underlying rendering nursing
kanang paa ko. to bacterial : cause/condition intervention, the
As verbalized by infection as After 4 hours involved. clients mother
the patinet. manifested by of rendering R : To assess participated in
the swelling of nursing causative/contributing preventive
O: the right foot. intervention, factors. measures and
-swelling of the patient will be >Note changes in skin treatment programs
right foot able to color, texture and turgor. for her child.
-skin redness participate in R : To assess extent of
-skin lesions preventive involvement/injury.
measures and >Determine depth of
treatment injury/damage to
program. integumentary system.
R : To assess extent of
LONG TERM involvement/injury. After week of
GOAL: >Inspect skin on a daily teaching the client,
basis, describing lesions he is seen doing a
After 1 week and changes observed. self-inspection of
the client will R : To assist with his lower
be taught what correcting/minimizing extremities.
a part of his condition and promote
body is at most optimal healing.
risk for skin >Keep the area
break down clean/dry, prevent
infection, and stimulate
circulation to
surrounding areas.
R : To assist bodys
natural process of repair.
>Review importance of
skin and measures to
maintain proper skin
functioning.
R : To promote
wellness.
>Discuss importance of
early detection of skin
changes and/or
complications.
R : To promote
wellness.
>Assist clients mother
in understanding and
following medical
regimen and developing
 program of preventive
care and daily
maintenance.
R : Enhances
commitment to plan,
optimizing outcomes.

DEPEDENT :
>Assist Nurse on duty in
give prescribed IV meds
as indicated.
R : To relieve
inflammation.

Discharge Planning
Get plenty of rest. This gives your body a chance to fight the infection.
 Raise the area of the body involved as high as possible. This will ease the pain, help
drainage and reduce swelling.
Please check the label for how much to take and how often. The pain eases once the
infection starts getting better.
Be sure to take the full course of antibiotics.
You may be advised to make a follow-up appointment with your doctor to make sure the
cellulitis is improving. Dont forget to do this.