Assessment Analysis/ Nursing Diagnosis Planning Implementation Evaluation

Subjective Data:  Decrease sensory Short Term: Independent: -Px experience normal skin tissue
 “matagal na yung perception related -In 20-30 mins, the -Assess patient's sensation
sugat” as to sensation patient will have a numbness and relief
verbalized by alteration relief from -Px maintains adequate nutritional
patient referring to secondary to numbness after -Provide compression intake as evidenced of being relief
ulcer leprosy taking up Niacin therapy service from pressure ulcer
 “kahit hawakan (vit B) as ordered
walang by the physician -Perform leg elevation -Px maintains activity level within
pakiramdam” or capabilities as evidenced of being
numbness -Asses patient's pain free of pressure ulcer
 “mahirap and relief
makalakad”
-Cleansing of the leg
Long Term: ulcer with warmed tap
Objective Data: -After 4-6 months water or saline is usually
 Edema on right of medication by sufficient
foot applying PHMB
 Pus in ulcer on the antimicrobial to the -Provide clean and
right foot ulcer as ordered by simple dressing
the physician, the technique using a
ulceration is dry stocking or bandage
and healed
Dependent:
-Topical administration
of Polyhexanide
(Lavasept) as ordered to
fasten healing

-Health teaching about

Self-medication of
prescribed antibiotics by
physician.
Actual Problem: Tuberculoid Leprosy
 Risk for:

Assessment Analysis/ Nursing Planning Nursing Care Plan/ Evaluation

Diagnosis
Subjective Data:  Risk for
 The patient states
that the lesions are
“madalas mainit”
as verbalized by
patient
 Occasional
numbness
 Muscle weakness
 “mahirap
maglakad”
 Immobility
Objective Data:
 Enlarged nerves in
the toes
 Chronic ulcers on
the right sole of
the feet
Implementation
Short Term: Independent: -Px experience normal skin
impaired tissue -In 20-30 mins, the patient tissue sensation
integrity r/t will have a relief from - assess for
sensation numbness after taking up superinfection -Px maintains adequate
alteration Niacin (vit B) as ordered by and nutritional intake as
secondary to the physician evidenced of being relief
leprosy - will clean the from pressure ulcer
wounds with saline
or nontoxic -Px maintains activity level
substances as within capabilities as
indicated evidenced of being free of
Long Term: pressure ulcer
-After 7-10 months of - Apply
medication by applying sterile bandage to
PHMB antimicrobial to the cover the wounds
ulcer as ordered by the and maintain
physician, the ulceration is aseptic technique.
dry and healed
-encourage patient
to increase
vitamins C intake
to fasten healing of
wounds

Dependent:

-Encourage to ma-
intain regular med-
ical by applying
Polyhexanide
(Lavasept)
antimicrobial as
ordered by
physician