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NURSING CARE PLAN FOR IMPAIRED SKIN INTEGRITY

ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION EVALUATION
Subjective:
“Ang dami ng
sugat niya sa
bibig” – as
verbalized by
the mother
Objective:
*Erythmatous
wounds
around
the mouth
*isru!tion o"
s#in sur"ace on
mouth
*estruction o"
s#in layer
bother
e!idermis and
dermis
$m!aired s#in integrity
r%t erythmatous wounds
on mouth secondary to
A!hthous &lcer
e"inition: Altered
e!idermis and%or
dermis'
(ac#ground )heory:
According to *lorence
+ightingale the
environmental
sanitation and !ro!er
hygiene !lays a vital
role in a !atient,s
healing !rocess- with
this- nursing care must
"ocus on mani!ulating
the environmental
sanitation and
im!roving or
enhancing !atient,s
hygiene'
S).:
At the end one /01 hour
nursing interventions- !atient
will be able to:
*(e "ree "rom "urther
com!lications'
*(e "ree "rom develo!ing
more ulcers'
2).:
At the end o" one /01 month
nursing interventions- !atient
will be able to:
*emonstrate timely healing
o" erythamous wounds
without com!lication'
$nde!endent:
01 Establish ra!!ort'
3: )o gain coo!eration and trust
41 Ascertain attitudes o" mother about
condition- note "or misconce!tions'
3: $denti"ies areas to be addressed in
teaching !lan- and !otential re"erral'
51 6ee! area clean- dry- care"ully dress
wounds'
3: )o avoid com!lications'
71 8rovided health teachings to mother:
9+utrition: :$nstructed to avoid eating
s!icy and hot "oods' 3: )his may lead to
aggreviating the ulcer "urther'
:$nstructed to eat "oods that are so"t- but
rich in vitamins and minerals' 3: So"t
"oods will be easy to eat thus not
touching the wounds and will not
!rovide more aggreviation to the ulcer'
9*luids: :$nstructed to avoid inta#e o" hot
"luids' 3: ;ot "luids will cause more !ain
to the ulcer'
e!endent:
<1 Administered antibiotics as !rescribed'
3: )o !rovide !ro!hyla=is and to control
in"ection'
>1 ?onitor and regulate $@*'
3: )o maintain adeAuate hydration'
Bollaborative:
C1 3e"er to nutritionist and dietician on
a!!ro!riate "oods and what to avoid'
3: )o have !ro!er "ood and "luid inta#e'
S).:
A"ter one /01 hour
o" nursing
interventions-
goal was !artially
met as evidenced
by:
*/D1 to
com!lications'
*A"ebrile
2).:
A"ter one /01
month o" nursing
interventions-
goal was
success"ully met
as evidenced by:
*Erythmatous
wounds are
healed
*+o "urther ulcers
were develo!ed'
NURSING CARE PLAN FOR RISK FOR IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS
ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION EVALUATION
Subjective:
“;indi na siya
#uma#ain
masyado ng
solid "oods- at
di na niya
nauubos isang
bote ng gatas
simula ng
dumami sugat
niya sa bibig” –
as verbalized by
the mother
Objective:
*Erythmatous
wounds
around
the mouth
*Slightly !aled
conjunctiva
*Bonsumed
only 5 oz' o" E
oz' served mil#
*loss o" a!!etite
3is# "or imbalanced
nutrition: less than
body reAuirements r%t
di""iculty o" inta#ing
"ood and "luids r%t
A!thous ulcer
e"inition: At ris# o"
inta#e o" nutrients is
insu""icient to meet
metabolic needs'
(ac#ground )heory:
According to @irginia
;enderson,s theory o"
07 human needs- it is
stated that a !erson,s
nutrition must be
adeAuate to achieve
o!timum level o"
homeostasis'
S).:
At the end one /01 hour
nursing interventions- !atient
will be able to:
*(e able to consume Eoz' o"
mil# during shi"t'
2).:
At the end o" one /01 month
nursing interventions- !atient
will be able to:
*emonstrate !rogressive
inta#e o" "ood'
$nde!endent:
01 Establish ra!!ort'
3: )o gain coo!eration and trust
41 Assist in !roviding oral care'
3: )o im!rove !atient,s taste'
51 Blean the area and avoid malodorous
stimulus'
3:)o avoid !atient,s loss o" a!!etite
71 8rovided health teachings to mother:
9+utrition: :$nstructed to avoid eating
s!icy and hot "oods' 3: )his may lead to
aggreviating the ulcer "urther'
:$nstructed to eat "oods that are so"t- but
rich in vitamins and minerals' 3: So"t
"oods will be easy to eat thus not
touching the wounds and will not
!rovide more aggreviation to the ulcer'
9*luids: :$nstructed to avoid inta#e o" hot
"luids' 3: ;ot "luids will cause more !ain
to the ulcer'
e!endent:
<1 Administered antibiotics as !rescribed'
3: )o !rovide !ro!hyla=is and to control
in"ection'
>1 ?onitor and regulate $@*'
3: )o maintain adeAuate hydration'
Bollaborative:
C1 3e"er to nutritionist and dietician on
a!!ro!riate "oods and what to avoid'
3: )o have !ro!er "ood and "luid inta#e'
S).:
A"ter one /01 hour
o" nursing
interventions-
goal was !artially
met as evidenced
by:
Subjective:
“+aintindihan #o-
lagi #o na
gagawin ang mga
yan'”
Objective:
*Oral care was
done to !atient by
mother as seen in
ward'
*8atient
consumes a total
o" > oz' during
shi"r'
2).:
A"ter one /01
month o" nursing
interventions-
goal was
success"ully met
as evidenced by:
*8atient eats
regularly and
consumes "ood
"ully'
NURSING CARE PLAN FOR READINESS FOR ENHANCED KNOWLEDGE: PREVENTION OF REOCCURRENCE OF ULCERS
ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION EVALUATION
Subjective:
“?aam- ano !o
yung mga
#ailangan #o
gawin !ara
hindi na ito
lumala !a o
mag#aroon
ulitF”Das
verbalized by
mother
Objective:
*Burious
*Activily as#
Aueries about
the disease
3eadiness "or enhanced
#nowledge: 8revention o"
reoccurence o" ulcers r%t
erythamous lesions
secondary to A!thous
ulcers'
e"inition: )he !resence
or acAuisition o"
cognitive in"ormation
related to a s!eci"ic to!ic
is su""icient "or meeting
healthDrelated goals and
can be strengthened'
(ac#ground )heory:
According to +ola G
8ender- ;ealth !romotion
is directed at increasing a
client,s level o" well
being' )he health
!romotion model
describes the multi
dimensional nature o"
!ersons as they interact
within their environment
to !ursue health'
)here"ore nursing actions
must "ocus on health
!romotion
S).:
At the end one /01 hour
nursing interventions-
!atient,s mother will be able
to:
*@erbalize understanding o"
health teachings
2).:
At the end o" one /01 month
nursing interventions- !atient
will be able to:
*emonstrate li"estyle
changes that !revents
reoccurrence o" a!thous
ulcer to child'
$nde!endent:
01 Establish ra!!ort'
3: )o gain coo!eration and trust'
41 8rovided health teachings to mother:
9+utrition: :$nstructed to avoid eating
s!icy and hot "oods' 3: )his may lead to
aggreviating the ulcer "urther'
:$nstructed to eat "oods that are so"t- but
rich in vitamins and minerals' 3: So"t
"oods will be easy to eat thus not
touching the wounds and will not
!rovide more aggreviation to the ulcer'
9*luids: :$nstructed to avoid inta#e o" hot
"luids' 3: ;ot "luids will cause more !ain
to the ulcer'
9Environment: :Assisted in cleaning the
room and !rovided adeAuate ventillation'
9;ygienic Bare: :emonstrated !ro!er
handwashing techniAue' :$nstructed to do
daily bath
:Assisted to do oral care to !atient'
518rovided health teachings to mother on how
to acAuire a!thous ulcer'
3: )o avoid triggers'
S).:
A"ter one /01 hour
o" nursing
interventions-
goal was !artially
met as evidenced
by:
Subjective:
“Salamat-
naiitindihan #o-
alam #o na
ngayon #ung ano
mga da!at
iwasan'”
Objective:
*Oral care done
as seen in ward'
*8ro!er
handwashing
techniAue done as
seen in the ward'
NURSING CARE PLAN FOR ACUTE INTERMITTENT PAIN
ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION EVALUATION
Subjective:
“Sa#it mama”
/while !ointing to
mouth1
*8ain Scale: >%0H
*Iuality:)hrobbin
g
**reAuency: $nterD
mittent Das !er
mother,s
descri!tion
Objective:
*Jith
erythmatous
wounds aroung
mouth
*Brying
**rowning
*8ointing to
ulcers
Acute intermittent
moderate !ain r%t
!resence o" ulcers around
mouth
e"inition: &n!leasant
sensory K emotional
e=!erience rising "rom
actual or !otential tissue
damage'
(ac#ground )heory:
According to @irginia
;enderson- $t is one o"
the 07 needs o" the client
is to be "ree "rom !ain
and be sa"e at all times'
S).: At the end o" eight /E1
hours nursing intervention-
client will be able to:
*?ani"est a decrease in !ain
*emonstrate use o" rela=ation
techniAues K other diversional
activities'
$nde!endent:
*8rovide bedside care'
3: (edside care hel!s in ma#ing the environment
clean and !leasing to the eyes K "eeling o" the
!atient- thereby decreasing !ain and !romoting
com"ort'
* 8rovide diversional activities such as !laying
and listening to music'
3: iversional activities and rela=ation techniAues
!rovides a re"reshing "eeling and e""ective way o"
diverting client,s attention to !ain inde!endently'
*$nstruct client to avoid moving as much as
!ossible i" unnecessary'
3: ?oving "reAuently that is unnecessary will
cause !ain to the !atient'
e!endent:
*Administer !ain reliver as !rescribed'
3: 8rescribed !ain relivers aids in alleviating the
!ain o" the !atient'
S).:
A"ter one /01 hour
o" nursing
interventions-
goal was !artially
met as evidenced
by:
*8atient sle!t'
NURSING CARE PLAN FOR RISK FOR INFECTION
ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION EVALUATION
Subjective:
“Ang dami ng
sugat niya sa
bibig” – as
verbalized by
the mother
Objective:
*Erythmatous
wounds
around
the mouth
*isru!tion o"
s#in sur"ace on
mouth
*estruction o"
s#in layer
bother
e!idermis and
dermis
3is# "or in"ection r%t
damage o" !rimary line
o" de"ense: s#in
e"inition: At
increased ris# "or being
invaded by !athogenic
microorganisms'
(ac#ground )heory:
According to *lorence
+ightingale the
environmental
sanitation and !ro!er
hygiene !lays a vital
role in a !atient,s
healing !rocess- with
this- nursing care must
"ocus on mani!ulating
the environmental
sanitation and
im!roving or
enhancing !atient,s
hygiene'
S).: At the end o" one
/01 hour nursing
intervention- client will
be able to:
*@erbalize
understanding o"
individual
causative%ris# "actors to
in"ection'
*$denti"y interventions
to !revent ris# o"
in"ection
*?aintain normal vital
signs'
$nde!endent:
01 Establish ra!!ort'
3: )o gain coo!eration and trust
41 6ee! area clean- dry- care"ully dress
wounds'
3: 8athogenic ?icroogranisms thrive in
moist environment'
51 8rovide bedside care'
3: (edside care hel!s in ma#ing the
environment clean and conducive to healing
!rocess thereby !reventing acAuisition o"
!athogenic microorganisms that causes
in"ection'
71 8rovide wound dressing
3: Jound dressing will #ee! the ulcer "ree
"rom in"ection'
<18rovided health teachings to mother:
9+utrition: :$nstructed to avoid eating
s!icy and hot "oods' 3: )his may lead to
aggreviating the ulcer "urther'
:$nstructed to eat "oods that are so"t- but
rich in vitamins and minerals' 3: So"t
"oods will be easy to eat thus not
touching the wounds and will not
!rovide more aggreviation to the ulcer'
9*luids: :$nstructed to avoid inta#e o" hot
"luids' 3: ;ot "luids will cause more !ain
to the ulcer'
e!endent:
>1 Administer antibiotics as !rescribed'
3: Antibiotics !revents develo!ment o"
in"ection
S).:
A"ter one /01 hour o"
nursing interventions- goal
was !artially met as
evidenced by:
*/D1 to com!lications'
*A"ebrile
2).:
A"ter one /01 month o"
nursing interventions- goal
was success"ully met as
evidenced by:
*Erythmatous wounds are
healed
*+o "urther ulcers were
develo!ed'
C1 ?onitor and regulate $@*'
3: )o maintain adeAuate hydration'
Bollaborative:
C1 3e"er to nutritionist and dietician on
a!!ro!riate "oods and what to avoid'
3: )o have !ro!er "ood and "luid inta#e'