NURSING CARE PLAN

Patient: LRB Age/ Sex: 4/F Admitting Diagnosis: Cellulitis Left Leg

ASSESSMENT NURSING PLANNING AND NURSING RATIONALE EVALUATION

CUES DIAGNOSIS OUTCOME INTERVENTION

SUBJECTIVE: Risk for infection After 8 hours of Independent: Goal met,

N/A related to nursing Assess vital Provides the
inadequate intervention and signs information guardian
primary defenses health teaching, about overall of the
the client will be fluid balance. patient
able to identify was able
OBJECTIVE: behaviors and Provide to
Lab result practices to proper hand Reduces rick identify
shows: prevent and reduce washing of cross- behaviors
increased the risk for technique to contaminatio and
eosinophil infection client and n/ bacteria practices
s-0.10 caregivers to
prevent
monocyte Teach the To prevent and
s-0.09 patients development reduce
guardian of of serious the risk
skin problems. for
Capillary assessment Basic skin infection
refill and ways to assessment
within 3 monitor for are color,
seconds skin moisture and
Good skin breakdown intact skin
turgor
Systematic
Monitor inspection
conditions at can identify
least once a impending
day for color problems
or texture early
 changes.
Determine
whether the
client is
experiences
loss of
sensation Prevents
entry of
Maintain bacteria
aseptic nosocomial
technique infection
with any
procedures.
Provide
routine site
care as
appropriate

Wide
Dependent: spectrum
Administer antibiotics
antibiotics may be used
as ordered prophylactica
lly, or
antibiotic
therapy may
be geared
toward
specific
organism

Provide
supplementa In presence
 l IV fluid as of reduced
necessary intake and/or
excessive
loss, use
parenteral
route may
correct
deficiency.

PREPARED BY:

RADOVAN, RACHEL GRACE

BSN3/ UPHSD-LASPINAS