ST.

ANTHONY’S COLLEGE
Nursing Department

NURSING CARE PLAN

Name of patient: J.C. Attending Physician:

Age: 19 years old Ward/Bed #: Impression Diagnosis: Obsessive Compulsive Disorder

Clustered Cues: Nursing Diagnosis Rationale Outcome Criteria Nursing Interventions Rationale Evaluation

SUBJECTIVE: Impaired skin Vulnerable to alteration GENERAL: INDEPENDENT: INDEPENDENT: GOALS MET
“Sometimes I have integrity related to in epidermis and/or At the end of 8hrs  Promote positive  To developed GENRERAL:
to spend long psychogenic factor dermis, which may nursing intervention coping strategies several effective  Identify
periods in the (e.g., obsessive compromise health the patient will be able that patient can coping strategies individual risk
bathroom. I keep compulsive disorder to: utilize other than that were utilized factor
thinking about  Identify frequent hand when he felt the
what is on the individual risk washing. urge to wash his
desks, and then I factor hands.
need to keep
washing my SPECIFIC:  Encourage the  To identify self- SPECIFIC:
hands” as patient At the end of 8 hrs. of patient to consciousness  Demonstrate
verbalized. assessment, verbalize his related to the healing of skin
interventions, and feelings and the appearance of lesions and
O:BJECTIVE: health education the impact that the hands made it assume a
 Hands red patient's condition will condition of his difficult to normal color.
and be able to skin has on his interact with peers  Participate in
chapped self-esteem. and feel prevention
with Doenges,M.E.  Demonstrate comfortable with measures and
several etal.(2016). healing of skin them. treatment
open areas. Nurse'sPocket Guide: lesions and program.
 Sore hands Diagnosis Prioritized assume a  Assess skin on a  To identify if
Interventions and normal color. regular basis and there is any
Rationales.  Participate in document your improvement/cha
V/S: (WITHIN Philadelphia. F.ADavis prevention assessment. nge in the
NORMAL) Company. measures and Educate patients appearance of the
BP= treatment and caregivers skin
TEMP= program. about proper skin
RR care.
PR=  Evaluate client’s  Educating
SP02= skin care patients methods
practices and to maintain skin
hygiene issues integrity enhances
their sense of self-
efficacy and
prevents skin
breakdown.

 Apply  For wound

appropriate healing and to
dressing best meet needs
of client

 Recommend  To reduce risk of

keeping nails dermal injury
short or wearing when severe
gloves inching/sore is
present.

DEPENDENT: DEPENDENT:
 Communicate  The physician can
with a physician give orders to
as appropriate meet wound
healing

COLLABORATIVE: COLLABORATION:
 Communicate  The WOCN can
with a wound, assist staff,
ostomy, and patient, and
continence nurse family in product
(WOCN). selection,
education, and
development of a
prevention plan.
  Assess client to  To control
learn stress- feelings of
reduction and helplessness and
engaged in deal with situation
alternate therapy
techniques

Student’s Name: Arzaga, Chery Lynn R. & Basañes, Romulo F.

Clinical Instructor: Mrs. Louwelyn Diasnes, RN