Patient’s Name: Ms.

XX Chief Complaints: Wound infection

Room/ Bed #: MISC 1 Diagnosis/ Impression: Ulcerated wound 1x1 cm on left thigh
Age: 5 months old Attending Physician: Dr. YY
General Objective: To promote safety through prevention of accidents, injury or other trauma and through the prevention of the spread of infection.
CUES NURSING RATIONALE SPECIFIC INTERVENTION RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES
Subjective: Impaired skin Break in the skin Within 8 hours of Independent: After 8 hours of
“napilas ni siya integrity related (wound, laceration, rendering nursing care 1. Note changes in skin 1. To assess extent of rendering nursing care to
tapos wala na to bacterial scrape, cuts) at PEDIA - CLMMRH, color, texture and turgor. involvement or injury the patient, the patient’s
talupangdan” infection I will be able to mother participated in
secondary to promote participation of 2. Keep the area 2. To assist body’s preventive measures and
Objectives: cellulitis caregiver in prevention clean/dry, prevent natural process of repair. treatment programs for her
Organisms in the skin measures and treatment infection, and stimulate child as evidenced by:
 Face grimace gain entrance to the regimen for the infected circulation to  The mother was able
noted dermis (S. areus/ Group area of the patient. surrounding areas. to verbalize
A streptococcus) understanding of
 Redness and 3. Apply appropriate 3. Wound dressings health teachings
lesion on left dressing protect the wound and  Lesions were kept
thigh noted the surrounding tissues. clean and dry

 Tight, glossy Skin on the left thigh is 4. Perform nail care to 4. Long and rough nails
appearance of swollen, red and tender, the patient increase risk of skin
the skin on the tight, and glossy damage
left thigh noted
5. Instruct folks to let 5. To prevent the patient
patient wear mittens from touching or
Impaired skin integrity scratching the infected
Other pertinent wound
data:
 Medications:
 clindamycin Dependent:
40mg IVTT 1. If indicated, administer
q6h medications such as
 gentamicin antibiotic in accordance
20mg IVTT to the 12 rights of drug
OD administration.
  fluconazole  Medication:
50mg/pptab References:  clindamycin  To stop the growth of
OD Belleza, M. (2017, 40mg IVTT q6h bacteria.
September 26).  gentamicin 20mg  To help fight bacteria
 HGB (g/dl): 93 Cellulitis. Retrieved and to treat severe or
IVTT OD
(0.5) from nurseslabs: serious bacterial
 HCT (%):0.29 https://nurseslabs.co infection.
(32) m/cellulitis/?  fluconazole  to prevent and treat a
 RBC (x 106 /µL): fbclid=IwAR12gIVs 50mg/pptab OD variety of fungal
3.27 YEOoGbaIrCH_3E8 and yeast infections
 WBC (x 10ᵌ /µL): 7prxG8LnuDj_bT_
5.7 AqAHXpNuvKbIE-
 Lymphocytes TTmzbTM
(%): 20
 Monocytes
(%):15

References:
Belleza, M. (2017, September 26). Cellulitis. Retrieved from nurseslabs: https://nurseslabs.com/cellulitis/?
fbclid=IwAR12gIVsYEOoGbaIrCH_3E87prxG8LnuDj_bT_AqAHXpNuvKbIE-TTmzbTM
Nanda Health. (2013, October 27). Impaired Skin Integrity related to Cellulitis Care Plan. Retrieved from Nanda Health: https://nanda-health.blogspot.com/2013/10/impaired-
skin-integrity-related-to.html
 COLEGIO SAN AGUSTIN – BACOLOD
COLLEGE OF HEALTH AND ALLIED PROFESSIONS
P.O. Box 120, B.S. Aquino Drive
Bacolod City 6100 Philippines

Nursing Care Plan

By:
Milleia Grace N. Bandolon
BSN 2-A Group 1