Sie sind auf Seite 1von 3

Nursing Care Plan

Student Name/Date: ____________Mark Doherty 10/3/07______________


Expected Outcomes
(Short term (8-48 hr.) reasonable Nursing Interventions/Rationale Outcome Evaluation
Nursing Diagnosis
expectations stated in measurable, List all interventions for each nsg. dx (include (Patient outcome noted as met or
(Dx, related to, & as evidenced by)
behavioral terms, i.e., action patient/family teaching) unmet/responses described)
verbs)
Knowledge deficit of management Patient and spouse will understand 1. Assess readiness to learn management Met. Patient and spouse understand
of visual impairment related to that patient will need assistance techniques of cellulitis from the patient that patient will need help with
patient being unfamiliar with facial with ADLs (toileting, eating, and spouse. It needs to be made sure ADLs. Asked questions to clarify
cellulitis as evidenced by the patient walking, taking meds) by end of that the patient and spouse are willing and backbriefed my teaching.
and spouse asking about what needs shift. to learn these interventions so they can
to be done to manage the cellulitis apply them. Met. Patient and spouse said they
and what kind of assistance the Patient and spounse will state 3 2. Explain to spouse to clear obstructions understand and stated at least 3
patient may need . techniques to manage cellulitis by along his path when ambulating. This techniques in managing the
discharge reduces chance of falls (Harkreader and cellulitis.
Hogan, 2004, p. 988)
3. Explain to spouse that rooms at home
should be well or brightly lit. This
prevents chance of pt. bumping into
things and injuring self and falling.
(Harkreader and Hogan, 2004, p. 988)
4. Explain to spouse that she needs to give
medications to client. Since his vision is
hindered, his wife is the only one who
can read the label for the correct meds.
5. Collaborate with dermatologist or
wound-care nurse to find ways to treat
and manage symptoms of cellulitis
(mainly the inflammation) that can be
used to teach the patient and spouse.
Dermatoligist and wound care nurse
can find other methods of treamtent and
possible medications.
6. Teach patient to moisturize skin to
prevent cracking and peeling. Cracks
and peels serve as portals of entry of
bacteria and this can lead to
complications such as cellulitis.
(http://www.mayoclinic.com, 2007)
7. Tell patient, when resting, to try to sit at
90 degrees with head straight to
promote maximum venous return to
prevent venous stasis. Venous stasis is a
risk factor for cellulitis. (Venes, 2005,
p. 373)
8. Teach patient and spouse to apply cold
(i.e.ice pack) if sympotms get worse
(increase in swelling and pain) Cold is a