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Patient’s Initial: B.

Age: 49y.o
Sex: Male
Medical Diagnosis: swelling and redness of Right leg cellulitis Right foot
Attending Physician: Dr. C
Date of Admission: January 9, 2018
Date of Discharge:

Plan of Care Problem Level of Care Plan of Action
Avoid or limit the following: 1. Impaired skin integrity (Wound) Promotive  Encourage patient to have adequate calorie intake with
*Carbonated and alcoholic beverages balanced protein and carbohydrates.
*Refined foods such as fries, pizza, fried chicken and chips
*Limit the intake of peanuts, cashews, green gram, peas,  Encourage patient to eat foods rich in vitamin C such as
lean meat, poultry, fish, eggs, millet, nuts and seeds, lentils, oranges, guavas, lemons, beans and cabbages and also to
beans and fermented soy. include flavonoid rich food in her diet such as onions,
*Vegetables such as potato, tomatoes as they are known to apples, tomatoes and citrus fruits.
aggravate VATA (Wind) and cause pain and discomfort.
*Milk and other dairy products such as butter, cheese and  Encourage patient to wear loose clothing
ghee are known to worsen symptoms.
*Avoid artificial sweeteners.
* Oily and fried food.  Instruct patient to avoid rubbing and scratching the wound.
*Caffeinated products and hydrogenated fats are best Preventive
avoided as they may further exacerbate the condition.  Instruct patient and significant others to monitor site of skin
*Avoid sweets and sugary foods that slow down the natural impairment for color changes, redness, swelling, warmth,
process of wound healing. pain, or other signs of infection.
Promote the following:
*Drink a lot of fresh fruit juices (without adding artificial  Instruct the patient and significant others to avoid
sugar) and ensure adequate hydration to flush away those massaging around the site of skin impairment.
*Take good proteins from soya, sprouts etc.
 Instruct the patient significant others not to position the
*Increase the intake of yellow, orange, and green vegetables client in the site of impairment.
which help boost immunity.
 Instruct patient to use pressure reducing devices, pillows
* An all-fruit diet for three days.
and foam wedge.
* Increase essential fatty acids from seeds and nuts like –
almonds, walnuts and flaxseeds.
* Eat plenty of green leafy vegetables and fresh fruits from
 Instruct client and significant others in proper wound care
organic sources. Vegetables such as beans, carrots, broccoli, Curative
including hand washing, wound dressing and wound.
cabbage and cucumber.
 Instruct client to continue applying prescribed bactifree
*Drink adequate amounts of water through the day. cream to the site of impairment.
*Food rich in flavonoids such as onion, garlic, ginger, grape  Instruct client to continue prescribe antibiotics such as
seeds are also beneficial. ampicillin sulbactam.
Rehabilitative  Advise Client and significant others to consult her physician
*Teach folk to provide a proper oral hygiene.
for follow-up check up.
*Teach proper disposal of body secretion.
*Emphasize the significance of proper hand washing.
*Instruct client to take daily bath. Promotive
2. Altered physical mobility  Encourage patient to execute passive or active assistive
*Instruct to wear clean clothes.
range of motion exercises to all extremities.
*Encourage to expose the linens under the heat of the sun.  Instruct the patient to facilitate early ambulation when
*Encourage to change beddings every week. possible. Advise the significant other to aid with each initial
*Encourage to wash towels every after 3 uses. change: dangling legs, sitting in chair, ambulation.
*Encourage to trim finger nails and foot care.  Encourage patient to independently perform simple activity
at her own pace such as combing her hair, changing clothes,
*Advice to use lotion or moisturizer to keep the skin moist and eating.
and prevent cracking and splitting
 Advise significant others to provide the patient rest periods
*Advice the folks to keep the surrounding clean. in between activities.
*Check and change the wound site and wound dressing
daily.  Instruct significant other to turn the patient every 2 hours or
*Avoid use of irritating soap as needed.
*Encourage not to over perform activities and have frequent Preventive  Advise to avoid strenuous activities such as washing clothes
rest periods, take afternoon naps. and lifting or moving heavy furniture.
*Instruct to avoid strenuous activities like laundering, lifting  Instruct significant others to always raise the side rails and
heavy objects. put important item close.
*Encourage to have adequate sleep at night for at least 6-8
Rehabilitative  Advise client to consult physician for follow-up
*Encourage to perform active or passive range of motion
*Encourage to perform activities of daily living as tolerated
and instruct folks to provide assistance when necessary.
*vitamin C (ascorbic acid)
Dosage: 100 mg/5mL
Route: PO
Frequency: OD
For protection against immune system deficiency
*zinc sulfate syrup
Dosage: 5ml
Route: P.O
Frequency: OD
For improve growth and fight infection and improve
absorption of nutrients
*vitamin b complex syrup
Dosage: 10mL
Route: P.O
Frequency: OD HRZE
Dosage: 2 tab
Route: P.O
Frequency: ODAC
To increase energy levels and maintain cardiovascular
health and beneficial in boosting RBC production;
beneficial in heart, health and brain support
Dosage: 15 mg/kg/day
Route: P.O
Frequency: q12
For pain reliever
Community Support:
*Encourage to visit the barangay health centre.
*Keep record of telephone number of the doctors, family
members, neighbours, and health agencies in case of
*Avail the health services offered by the nearest health
centre such as check-up.
*Encourage client to have faith and trust God at all times.
*Encourage client to continue participating in religious
activities and to contact with spiritual advisers.
*Provide support with her religious beliefs.
*Instruct the family to be with the client during prayer
*Encourage to verbalized feelings about present condition.
*Encourage to seek spiritual counselling if needed.
*Instruct client and her family to make use of health
*Instruct client or significant other to visit the physician
for follow- up check up: Dr. A’s & Dr. R’s – clinic on
February 9, 2018