XI.

NURSING CARE PLAN

Assessment Nursing Analysis Planning Intervention Rationale Evaluation

Diagnosis

Subjective cues: Impaired skin Cellulitis is an acute, Goal: Independent: Was the client’s
“Kailangan talaga integrity spreading and potentially Determine etiology.  Prior significant other
palaging malinisan related to serious infection of dermal After 2 weeks of assessment able to verbalize
yung sugat niya para infection as and subcutaneous tissue, nursing of wound measures to protect
hindi na magka manifested characterized by red, intervention, the etiology is and heal the tissue,
complication. by tender skin at the site of client’s wound will critical for including wound
Naaawa nga ako eh, destruction bacterial entry. Organisms be able to decrease proper care to prevent
isolated in cellulitis further
hindi niya na of dermis, in size and has identification
include Staphylococcus complications?
magawa mga dating irritation and increased of nursing
aureus and Streptococcus ___Met
ginagawa niya facial granulation tissue. interventions. ___Unmet
pyogenes. Cellulitis is a
ngayon,” stated by grimace.
common condition in
the client’s older people, to tend to Objectives: Were the resources
significant other. suffer from lower limb Assess site of impaired  Redness, available to the
edema. Infection enters After 30 minutes of tissue integrity and its swelling, nurse and client
Objective Cues: the skin in a variety of nursing condition. pain, burning, maximized?
 Destruction ways, including surgical intervention, the and itching ___Met
of skin layers wounds, stasis eczema or client’s significant are indication ___Unmet
 Irritation leg ulcers, minor abrasions other will be able to of
 Facial and IV drug injection describe measures inflammation Were the
Grimace sites. The infection rapidly to protect and heal and the interventions
spreads through the the tissue, including body’s appropriate to the
lymphatic system then wound care to immune client’s condition?
inflammation on the prevent further system ___Met
dermis and cellulitis ___Unmet
complications. response to
occurs. localized
Reference: Ebersole & tissue Were all
Hess’ Toward Healthy trauma. interventions
Aging, 8th edition, Page 60 acceptable to the
Assess characteristics of  This findings client?
wound, including color, will give ___Met
size, drainage and odor. information ___Unmet
on extent of
Were all
Assess changes in body injury.
interventions
temperature specifically
enough to solve the
increased in body  Fever is health problem?
temperature. systematic ___Met
manifestation ___Unmet
of
inflammation
and may
Provide tissue care as indicate the
needed. presence of
infection.

 The dressing
replaces the
protective
function of
the injured
Keep a sterile dressing tissue during
technique during wound the healing
care. process.

Wet thoroughly the  Reduces risk

dressings with sterile for infection.
normal saline solution
before removal.  This will ease
the removal
by loosening
adherents
and
decreasing
pain.
Dependent/Collaborative
Administer antibiotics as  Wound
ordered. infections
may be
managed well
and more
efficiently
with topical
agents,
although IV
antibiotics
may be
indicated.

Notify physician if further  For proper

complication occurs. treatment.