NURSING CARE PLAN

Name of Patient: R.B. Attending Physician: Dr. V/ Dr. A

Age: 24 Impression/Diagnosis: Basal Cell Carcinoma right cheek
Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Interventions Rationale Evaluation
12/16/09 8:00
Risk of infection related At increased risk for 1. R.B will be free from 1. Note risk factors for 1. GOAL MET
to inadequate primary being invaded by infection as manifested the occurrence of R.B was not febrile
defenses: broken skin pathogenic by absence of fever infection. Temp=36.2C , did not
microorganisms. (>37.8C), purulent complain and was not
discharge, pain and 2. Observe for signs of observed to have any
Wound contamination, erythema in his ulcerated infection at ulcerated 1-3 To serve as baseline pain, erythema and did
wound separation, and mass by December 16, mass: erythema, pain, data and contributing not manifest purulent
foreign bodies delay 2009 and until discharge purulent discharge factors discharges.
wound healing. Infection
impairs all dimensions It 2. R.B will practice 3. Monitor vital signs
prolongs the proper care and hygiene every 4 hours.
inflammatory phase, of skin especially with the 2. GOAL MET.
impairs the formation of ulcerated mass at right 4. Demonstrate and allow 4. A first-line defense R.B takes regular baths
granulation tissue, and cheek by December 16, R.B and folks to practice against health-care and changes wound
inhibits proliferation of 2009. proper hand-washing associated infections dressing thereafter.
fibroblasts and deposition technique
of collagen fibers. All 5. To reduce bacterial
wounds are 5. Assist in bathing or colonization
contaminated at the time encourage regular
of injury. Although body bathing: full bath
defenses can handle the
invasion of 6. Maintain sterile
microorganisms at the technique for all invasive
time of wounding, badly procedures such as IV,
contaminated wounds catheterization 6-7. To reduce or correct
can overwhelm host existing risk factors
defenses. Trauma and 7. Change wound
existing impairment of dressing as indicated
host defenses also can using proper technique
contribute to the for changing/ disposing
development of wound of contaminated
infections. materials.

Source: Porth, C. 8. Emphasize taking of 8. Premature

2005.Pathophysiology: antibiotics as directing. discontinuation of
Concept of Altered Following correct dosage treatment when client
Health States 7th edition and duration begins to feel well may
result in return of
Doenges, C. 2008. infection and potentiate
Nurses Pocket Guide: drug resistance strains.
Diagnoses, Prioritized
Interventions and 9. Maintain adequate To avoid bladder
Rationales 11th edition hydration (1,900ml- distention and urinary
2,400ml) per day. stasis; prevents/ reduces
risk of UTI

10. Encourage intake of To help develop and

vitamin C-rich foods such increase function of
as: citrus fruits, immune system
tomatoes, guava