Assessment

Nursing Diagnosis

Planning

Intervention

Rationale

Evaluation

NURSING CARE PLAN FOR JASEL (FEBRUARY 26-28, 2007) Following Subjective: “May mga sugat ako.” as verbalized by the patient. Objective: • Disruption of skin surface at the ® lower extremity. • Wound is 5mm in diameter. • Localized erythema • Purulent discharge • (+) pruritus on the site of the wound. • (+) pain Impaired skin integrity related to inflammatory response secondary to infection. nursing a 3-day ♦ Assessed and skin. sensation. and wounds observed ♦ Establishes comparative baseline providing for opportunity At the end of the 3-day nursing intervention, the client was able to display improvement in wound healing as evidenced by: • Minimized presence of wounds. ♦ Demonstrated good skin hygiene, e.g., wash and • Absence of redness or erythema. • Absence of carefully. thoroughly pat dry ♦ Maintaining clean, • Several wounds dry skin provides a barrier to infection. Patting reduces skin risk dry of • Minimized erythema. • Minimized purulent discharge. • Wounds are still at least 5mm in diameter. (Continue cleaning the wound with disinfectant) • Presence of instead of rubbing dermal trauma to fragile skin. ♦ Instructed family to maintain clean, dry clothes, shirt). preferably cotton fabric (any T♦ Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for infection. intervention, Noted color, turgor, Described measured and or changes.

the client will be able to display improvement in wound healing as evidenced by: • Intact skin minimized presence of wound. • Wound is less than 5mm in diameter.

timely intervention.

have dried up.

purulent discharge. • Absence itchiness. of

itchiness. (Continue

1

Assessment

Nursing Diagnosis

Planning

Intervention

Rationale

Evaluation

♦ Improved ♦ Emphasized importance adequate and fluid intake. of nutrition improve condition.

nutrition skin

and hydration will

♦ Providing the family ♦ Demonstrated to with solution them healing in alternative assists optimal less instructing client to avoid scratching the wound) with the family members on how to make a guava decoction to apply to the wound as alternative disinfectant. ♦ Long ♦ Instructed family to clip and file nails regularly. ♦ Wound ♦ Provided applied and wound and surrounding tissues. dressings the protect the wound and rough nails increase risk of skin damage.

expensive resources.

dressings carefully.

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Assessment

Nursing Diagnosis

Planning

Intervention

Rationale

Evaluation

NURSING CARE PLAN FOR THE FAMILY (MARCH 5-7, 2007) Following Subjective: “Makati po ang ulo ko.” as verbalized by the patient. Objective: • Presence of small, white flecks on hair shaft at the back of the head (eggs of lice). • Pruritus scalp. • Excoriation on the scalp. • Rough, dry hair. on the Impaired skin integrity (scalp) related to parasitic infestation secondary to direct transmission of the organism. nursing to a 3-day ♦ Assessed head lice. each ♦ The easily contact. ♦ Demonstrated a warm to ♦ Vinegar remove helps to any organism is At the end of the 3-day nursing intervention, the client was able to display timely healing of scalp excoriations without complications as evidenced by: • Minimized excoriations on the scalp. • Minimized itchiness the hair comb ♦ Fine-toothed combs help remove nit shells from the hair shaft and reduces risks reinfestation. ♦ Instructed treatment immediately once the ♦ This condition for on the scalp. • Presence lice of egg intervention, timely scalp without as family member for transmitted

the client will be able display of healing

by direct physical

excoriations complications evidenced by:

family how to make vinegar (1 cup solution

remaining nits or nit shells from the hair shaft.

• Absence of small, white flecks on hair shaft (egg lice). • Absence of pruritus on the scalp. • Absence scalp. of

vinegar mixed with 1 cup water). ♦ Combed patient’s fine-toothed

thoroughly with a dipped in vinegar.

(Continue

excoriations on the

combing hair with fine-toothed comb).

family to start the

spreads rapidly.

3

Assessment

Nursing Diagnosis

Planning

Intervention there is presence of eggs at the hair shaft. ♦ Warned children

Rationale

Evaluation

not to share combs, brushes and hats with other people.

♦ Head lice can also be infested transmitted through combs, indirectly

brushes, wigs, hats ♦ Instructed family to wash all clothing, towels beddings in and hot and beddings. ♦ Washing clothings water in all hot prevents

water at least 54˚C or hang under the sun to dry.

reinfestation.

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