CEBU INSTITUTE OF TECHNOLOGY - UNIVERSITY

COLLEGE OF NURSING

NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

(Subjective & (Dependent,
Objective) Independent &
Collaborative)
Independent:
Subjective: Impaired skin integrity Pressure ulcers are After 4 hours of nursing  Assess between  Pressure ulcer After 4 hours of nursing
related to pressure injuries to skin and interventions, the folds of skin between folds interventions, the
“Mu init akong luyo. ulcer secondary to underlying tissue patient will: of skin are patient was able to:
Murag naa sya samad.” prolonged immobility. resulting from commonly
As verbalized by the prolonged pressure  Be relieved overlooked  Be relieved
patient. on the skin. Bedsores from pain  Increase the  To decrease from pain as
most often develop
 Have reduce frequency of pressure over evidenced by
on skin that covers
Objective: risk of further turning every 2 time and to decreased
bony areas of the
body, such as heel, impairment of hours promote good redness of
 Presence of ankles, hips and skin circulation wound.
pressure ulcer tailbone.  Have improved  Apply wound  Protects the  Have improved
on the coccyx. blood dressing wound and blood
circulation regularly prevents circulation
 Injury of the  Patient’s s/o Dependent: infection.  Patient’s s/o
epidermis. will  Ensure  To improve assisted in
demonstrate adequate tissue healing wound
understanding dietary intake and prevent dressing.
and skill in as prescribed malnutrition.
wound caring. by dietician.
  Prevent ulcer  To prevent
from being contamination.
exposed to
urine by using
catheter.

Name of Student : Date of Clinical Exposure :

Year Level : Area of Clinical Exposure :
Clinical Instructor: