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Nursing Care Plan

ASSESSMENT

DIAGNOSIS

PLANNIG

INTERVE
NTION

EVALUATION

S : Namamaga
at namumula ang
kanang paa ko.
As verbalized by
the patinet.

Impaired skin
integrity related
to bacterial
infection as
manifested by
the swelling of
the right foot.

SHORT
TERM GOAL
:
After 4 hours
of rendering
nursing
intervention,
patient will be
able to
participate in
preventive
measures and
treatment
program.

INDEPEND
ENT :
>Identify
underlying
cause/condit
ion
involved.
>Note
changes in
skin color,
texture and
turgor.

To assess
extent of
involvement/i
njury.

After 4 hours of
rendering
nursing
intervention, the
clients mother
participated in
preventive
measures and
treatment
programs for her
child.

LONG TERM
GOAL:

>Determine
depth of
injury/dama
ge to
integumenta
ry system.

To assess
extent of
involvement/i
njury.

>Inspect
skin on a
daily basis,
describing
lesions and
changes
observed.

To assist with
correcting/min
imizing
condition and
promote
optimal
healing.

>Keep the
area
clean/dry,
prevent
infection,
and
stimulate
circulation
to
surrounding
areas.

To assist
bodys natural
process of
repair.

>Review
importance
of skin and

To promote
wellness.

O:
-swelling of the
right foot
-skin redness
-skin lesions

After 1 week
the client will
be taught what
a part of his
body is at most
risk for skin
break down

To assess
causative/cont
ributing
factors.

After week of
teaching the
client, he is seen
doing a selfinspection of his
lower
extremities.

measures to
maintain
proper skin
functioning.
>Discuss
importance
of early
detection of
skin
changes
and/or
complicatio
ns.
.
DEPEDEN
T:
>Assist
Nurse on
duty in give
prescribed
IV meds as
indicated.

ASSESSMENT

DIAGNOSIS

PLANNING

S : Medyo ninerbyos na ako


ng makausap ko
ang doctor. As
verbalized by
the patient.

Fear related to
unfamiliarity
with
environmental
experiences as
evidenced by
increased
alertness.

After 8 hours INDEPENDENT :


of rendering
>Note degree of
nursing
incapacitation.
intervention,
the client will
lessen his
fear.

-increased
alertness
-v/s taken as
follows :
P : 125 bpm
R : 22 cpm

To promote
wellness.

To relieve
inflammation.

INTERVENTION

RATIONALE

To assess
degree of fear
and reality of
threat
perceived by
the client.

>Measure vital
signs/physiological
responses to situation.

To assess
degree of fear
and reality of
threat
perceived by
the client.

>Stay with the client or

Sense of

EVALUATION
After 8 hours of
rendering nursing
intervention,
clients fear has
lessened.

make arrangements to
have someone else be
there.

abandonment
can exacerbate
fear.

>Identify clients
partner the
responsibility for the
solutions.

Enhances
sense of
control

>Instruct patient in use


of
relaxation/visualization
and guided imagery
skills.

Provides a
helpful and
healthy outlet
for energy
generated by
fearful
feelings and
promotes
relaxation.

ASSESSMENT

DIAGNOSIS

PLANNIG

INTERVENTION

EVALUATION

S : Namamaga at
namumula ang
kanang paa ko.
As verbalized by
the patinet.

Impaired skin
integrity related
to bacterial
infection as
manifested by
the swelling of
the right foot.

SHORT TERM
GOAL :
After 4 hours
of rendering
nursing
intervention,
patient will be
able to
participate in
preventive
measures and
treatment
program.

INDEPENDENT :
>Identify underlying
cause/condition
involved.
R : To assess
causative/contributing
factors.
>Note changes in skin
color, texture and turgor.
R : To assess extent of
involvement/injury.
>Determine depth of
injury/damage to
integumentary system.
R : To assess extent of
involvement/injury.
>Inspect skin on a daily
basis, describing lesions
and changes observed.
R : To assist with
correcting/minimizing
condition and promote
optimal healing.
>Keep the area
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,

After 4 hours of
rendering nursing
intervention, the
clients mother
participated in
preventive
measures and
treatment programs
for her child.

O:
-swelling of the
right foot
-skin redness
-skin lesions

LONG TERM
GOAL:
After 1 week
the client will
be taught what
a part of his
body is at most
risk for skin
break down

After week of
teaching the client,
he is seen doing a
self-inspection of
his lower
extremities.

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.