Ateneo de Naga University

COLLEGE OF NURSING
Naga City

NURSING CARE PLAN

ASSESSMENT NURSING DIAGNOSES RATIONALE PLANNING IMPLEMENTATION RATIONALE EVALUATION

( ) brownish Chronic pain related to Venous insufficiency Goal: Cleaning the area of The skin must be kept After five days of
pigmentation on the venous insufficiency results from After five days of ulceration and moist, clean and free nursing interventions,
ankles as manifested by obstructed venous nursing interventions, changing of the from any bacteria that the client stated that
( ) ulceration ulcerations and pitting valves in the legs and the client will be in dressing may slow the healing she’ feeling better
edema it involved superficial minimal pain, swelling progress. since she is in minimal
approx. 4cm x 7cm
and deep leg veins. will recede and to no pain and the
on medial aspect of
absence of the 1+ Keep the affected leg Leg elevation swelling receded as
left ankle Venous ulceration is pitting edema and the elevated frequently at decreases edema, and well as no pitting
( ) 1+ swollen considered as most affected lower least 15-30 minutes) it promotes venous edema noted, and the
pitting edema on the sever complication of extremities will be in throughout the day return as well provides affected lower
left leg chronic venous their proper circulation and let the client sleep symptomatic relief. extremities shows
( ) skin warm to insufficiency. pattern. with the leg elevated normal blood
touch at most 6 inches circulation within.
This can also be
(+) venous stasis associated with other Recommend Wearing stockings
(+) posterior tibial conditions and compression of reduce venous pooling
pulses are present underlying factors superficial veins with and enhances venous
affecting the elastic compression return. This can also
but weak
circulation of the lower stockings. prevent further
extremities. formation of
( ) popliteal pulse ulcerations.

Avoid long periods of Let the client flex and

sitting or standing. extend legs, feet and
Exercise (walking is ankles about 5-10
beneficial) times every 30-45
 minutes to keep the
blood flowing in the
leg veins.

Administer antibiotics Oral antibiotic

as prescribed by the treatment is warranted
physician. if the infection is still
suspected.

Name of Patient: Mrs. Han Submitted by: Audrey Ann G. Acob Submitted to: Mrs. Richa Estrada, RN
Area/Ward: Medical Ward Rotation/Date: 8th Rotation Date Received: December 13, 2020