SAULT COLLEGE OF APPLIED ARTS AND TECHNOLOGY

Care Plan by JOIDA MAE ESPER I. CANONO IEN-ENP

Code Status: _DNR_

Tubes: IVC at right hand Dressing: HYGEOL, HYDRAFERA BLUE, VASHE,
Admitting Diagnosis: Allergies: Fish, Chicken CALMOSEPTINE, ADAPT STRIP PASTE, MESORB
Coexisting Illness(es): COPD, CAD, HTN, Dyslipidemia, Gout Isolation: CONTACT
VS: BP: 98/65, PR- 88, RR- 18, T- 36.6 Wt: 86.6 kg Mobility: level C Lift/Transfer: Lift/Transfer DEPENDENT
Diet: Regular IV: Normal Saline @ 125 ml/hr LBM: 26/11/22 Level of Risk for Falls: High
Oxygen: Room air O2 Sat: 98% Other: possible VAC dressing on Monday

ASSESSMENT PLANNING
Behaviour/Responses/Findings Nursing Interventions EVALUATION
Nursing AMB/AEB Goal
Diagnosis

Subjective: Impaired Skin pressure ulcers as Pressure ulcer will -Perform skin The patient will
Bedbound 3 weeks prior and Integrity related evidence by improve as evidenced assessments and Use experience the
since the day of admission. to immobility and disruption of by a reduction in size of the Braden Skin healing of current
With poor oral intake for the malnutrition epidermal and and absence of Assessment Scale to pressure wounds,
past 2 weeks. dermal tissues drainage determine the prevention of
patient’s risk for further skin injury
pressure injuries. and maintain
Objective: optimal skin
Pt’s weight is 86.6 kg. - Stage pressure ulcers integrity
Contractures are note in both correctly.
upper and lower extremities. Correct staging of skin
stage 3 pressure ulcer on her breakdown assists in
coccyx, buttocks, and right heel. proper management
Pt takes the following and continuous
medications: ASA 81mg PO assessment.
Daily, Bisoprolol 2.5 mg PO
On IV fluid of PNSS at 125 -Identify additional risk
ml/hr. factors.
Diagnostic work shows: WBC
12.7 HGB – 8, Neutrophils – -Collaborate with
10.95, VBG Hgb – 101, Na- 135 wound care experts.
Tissue culture R foot – Staph
Aureus - Encourage nutrition
and hydration.
V/s: BP: 98/65, PR- 88, RR- 18, T- 36.6 Poor nutrition and
hydration interfere
with immune function
as well as collagen
production and tensile
strength of the skin.

- Keep skin clean and

dry

- Perform necessary
wound care

- Assess and manage

pain

- Assess for
incontinence of bowel
or bladder

- Reposition patient at
least every 2 hours or
more frequently as
needed
 ASSESSMENT PLANNING

Behaviour/Responses Nursing Interventions EVALUATION

(data collection information and
Nursing Diagnosis AMB/AEB Goal
(including time frame)
observations)
Notes:

SBAR: