NURSING CARE PLAN

Cues Nursing Diagnosis Rationale to Nursing Goals and Objectives Nursing Rationale to Nursing Evaluation
Diagnosis Interventions Interventions
Subjective: Impaired skin integrity The most common Short term range Independent: Short term:
“I have a wound, as related to cause includes After 4 hours of  Assessed skin,  Establishes The patient shall
verbalized by the inflammatory response nursing intervention, noted color, comparative participate in
physical trauma
patient secondary to infection. the patient will turgor, and baseline prevention measures
(e.g., car accident, participate in sensation, providing and treatment program.
Objective: sports injury, cuts, prevention measures described and opportunity for
Temperature: 37 oC (98 blunt trauma, etc.,). and treatment program measured timely
o
F) Other causes can wounds and intervention.
Pulse rate: 88 be related to Long term range observed Long Term:
beats/min. Following a 1 week changes At the end of the 1
Respirations 24 thermal factors nursing intervention, week nursing
cycles/min. (e.g., burns, the client will be able  Demonstrated  Maintaining intervention, the client
Blood Pressure: 136/90 frostbites), or to display good skin clean, dry skin was able to display
mmHg chemical injury improvement in wound hygiene, e.g., provides a improvement in wound
(e.g., adverse healing as evidenced wash barrier to healing as evidenced
Height: 177.8 cm by: thoroughly and infection, by:
reactions to
(5’10”)  Intact skin or pat dry patting skin dry  Minimized
Weight: 72. 7 kg (160 drugs), infection, minimized carefully. instead of presence of
lb.) nutritional presence of rubbing wounds
imbalances, fluid wound. reduces risk of  Several wounds
 Pain imbalances, and  Wound is less dermal trauma t have dried up.
 Wound altered circulation than 9cm fragile skin.  Minimized
laceration 9cm (3.5inch) erythema.
(e.g., pressure
(3.5 inch) laceration  Minimized
ulcers).  Absence of  Instructed  Skin friction purulent
redness or family to caused by stiff discharge
erythema. maintain clean, or rough
A break in tissue  Wounds are
 Absence of dry clothes, clothes leads to
integrity is normally still at least
purulent preferably irritation of 9cm (3.5inch)
repaired by the cotton fabric
body very well, discharge (any T—shirt). fragile skin and laceration
though there are  Absence of increases risk (continue
itchiness  Emphasized for infection. cleaning the
circumstances that
importance of  Improved wound with
it doesn’t repair it at adequate nutrition and disinfectant)
all and replaces the nutrition and hydration will  Presence of
damaged tissue fluid intake. improve skin itchiness. 9
with connective condition continue
tissue. When tissue  Demonstrated instructing
to the family  Providing the client to avoid
integrity is left
members on family with scratching the
untreated, it could how to make a alternative wound)
cause local or guava solution assist
systemic infection decoction to them in optimal
and ultimately lead apply to the healing with
to necrosis. wound as less expensive
alternative resources.
disinfectant.
Other factors also
include age, weight  Instructed
loss, poor nutrition family to clip  Long and rough
and file nails nails increase
and hydration,
regularly. risk skin
excessive moisture damage.
and dryness,  Provided and
smoking, and other applied wound  Wound
conditions affecting dressing dressing protect
blood flow. carefully the wound and
the surrounding
tissues.
Source: Kozier, B. et
al. Fundamentals of
Nursing (8th Ed.). Dependent:
Pearson Education  Administer
South Asia Pte Ltd. prescribed pain  To relieve pain
medications, and prevent
antibiotics and infection and
other complications.
medications

Collaborative:
 Refer to a
wound care  For advice
specialist for a from specialist.
treatment when
indicated.