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NURSING CARE PLAN

Assessment

Nursing Diagnosis

Analysis

Objective:
- Presence of
rashes on the
lower
extremities
- Edema on
lower
extremities

Impaired
skin
Integrity related
to Inflammation

Inflammation
in
the small blood
vessels
as
manifested
by
rashes
and
edema resulting
to impaired skin
integrity.

Objectives

Nursing
Intervention

After 7 hours of
Provided
nursing
protective
interventions the
measures by:
client will be able 1. keeping area
clean and dry,
to display
carefully address
improvement of
rashes and
skin integrity as
edema; and
evidenced by
intact skin.
2. Avoiding or
limiting use of
plastic material.
Remove wet and
wrinkled linens
promptly.
Collaborative:
Administered
Cefuroxime 550
mg/IV as
prescribed by the
physician.

Rationale

Evaluation

After 7 hours of
nursing
1. To assist body’s interventions the
natural process of client was able to
display
repair and
improvement
of
prevent any
skin integrity as
further
evidenced
by
complications
intact skin.
such as infection
from occurring.
2. Moisture
potentiates skin
breakdown

Cefuroxime is
indicated to
maintain normal
skin and skin
structure.

NURSING CARE PLAN Assessment Subjective: . 1. 2. Evaluation After 7 hours of nursing interventions the client was able to perform mobilization. After 7 hours of nursing intervention. Paracetamol is for pain relief. Discussed the importance of ambulation through role play. Assisted in ambulating. pain. 2. prolonged bed rest and imposed activity restriction Presence of pain on the lower left extremity resulting to impaired mobility. .Imposed activity restriction Nursing Diagnosis Analysis Objectives Nursing Intervention Impaired mobility related to weakness. To establish knowledge base within the patient’s understanding capacity.Verbal report of weakness and pain (4/10) on the left lower extremity Objective: . Administered Paracetamol PRN as ordered by the physician. Rationale 1. To promote mobility. the client will be able to perform optimum mobilization.Prolonged bed rest . Collaborative: 1.

Rationale 1. Body image disturbance related to skin rash Inflammation as evidenced by rashes and edema has altered the integrity of the skin resulting to psychological effect on the patient about her body image.restlessness due to anxiety Objectives Nursing Intervention After 7 hours of nursing intervention. frustration. and 2. Acknowledged and accepted 1. To maintain 2. Objective: . the patient will be able to regain high levels of selfesteem as evidenced by: 1.NURSING CARE PLAN Assessment Nursing Diagnosis Analysis Subjective: “Ate. mawawala din po ba ito (rashes) agad? Kasi sasayaw po ako sa school namin eh. 3. . family. Encouraged open lines of family interaction communication with each other and to provide and with ongoing support rehabilitation for patient and team. verbalization of positive selfconcept. Prepares patient for 3. verbalization of expression of acceptance of feelings of self in situation. 2. Acceptance of this feeling as a normal response to what has occur facilitates resolution. Role play social reaction of others Evaluation After 7 hours of nursing interventions the client was able to perform mobilization.” as verbalized by the client.

absence of Nursing Intervention Collaborative: Administered Paracetamol PRN as ordered by the physician. verbalization of sleep satisfaction. di siya makatulog ng maayos. Objective: . the patient will be able to regain normal sleeping pattern as evidenced by: 1. 2. and 3. Disturbed sleeping pattern related to pain Presence of pain causes discomfort leading to disturbed sleeping pattern. verbalization of pain relief. absence of dark circles . the patient was able to regain normal sleeping pattern as evidenced by: 1. 2. verbalization of pain relief. and 3. To begin to incorporate changes in body image.situation of concern to patient. Rationale Evaluation Paracetamol is for After 1-2 days of pain relief. verbalization of sleep satisfaction. NURSING CARE PLAN Assessment Nursing Diagnosis Analysis Subjective: “Gising siya nang gising tuwing gabi. “Masakit po kasi binti ko. nursing intervention.drowsiness as manifested by frequent yawning . 4.” as verbalized by the mother.presence of dark Objectives After 1-2 days of nursing intervention. and anticipates way to deal with them. 4.” as verbalized by the patient. Encouraged patient to look at or touch affected body part.

Prepared by: RLE 2 of 2 NUR 6 Submitted to: Sir Les Paul Valdez Date: March 13. around the eyes.circles around the eyes dark circles around the eyes. 2014 THANK YOU SIR!!  .