FAR EASTERN UNIVERSITY

Institute of Nursing
Jonathan Dimaculangan
BSN 109 Nursing Care Plan
Cues Problem Analysis Goal and Interventions Rationale Evaluation
Objectives

Subjective: Impaired skin Altered Goal:

integrity epidermis
“Kapag related to and/or dermis After 8 hours of After 8 hours of
kinukuhanan impaired nursing the nursing
ako ng BP, circulation intervention, the intervention, was
sumasakit ang client will to the client will be
braso ko.” verbalize feeling able to verbalize
of increased self feeling of
esteem and increased self
ability to manage esteem and
“Pati nga yung situation ability to manage
swero ko nilipat situation?
kasi parang
sumsakit at ___yes
nangangati ako”
___no

Why?
“ Simula ng Objectives:
magkaroon ako
ng magkaroon After 1 hours of
ako ng nursing
hypertension, intervention, the
namumula at client will be able
sumasakit na to
ang kaliwang
bahagi ng braso
ko.”
Assess etiology /
precipitating Assess for referred To help determine
factors pain, as appropriate possibility of
“parang may underlying
bmaliliit na bato condition or organ
akong nakikita dysfunction
sa ihi ko” requiring
treatment

Fundamentals of
Objectives: Determine Nursing by Kozier
nutritional status and Erb, 8e
(+) generalized and potential for
tenderness delayed healing or
tissue injury
(+)muscle exacerbated by
guarding malnutrition

Intake: 400cc

Output: 90 cc

(+) dry skin Assess extent of Obtain history of To rule out

involvement/injur condition, including worsening of
(+) dry lips y age at onset, date underlying
of first episode, condition/
duration of problem, development of
and changes that complication
occurred over time
 Fundamentals of
Nursing by Kozier
and Erb, 8e

Identifies areas to
Determine impact Ascertain attitudes be addressed in
of condition of individual about teaching plan and
condition (cultural potential referral
values) Note needs
complications
Fundamentals of
Nursing by Kozier
and Erb, 8e

Note presence of Skin is particularly

compromised important avenue
vision, hearing, or of communication
speech. for this population
and, when
compromised,
many affect
responses.

Fundamentals of
Nursing by Kozier
and Erb, 8e
Correct/minimize Keep the area
condition and clean/dry, carefully
promote healing dress wounds, To assist body’s
prevent infection, natural process of
manage repair
incontinence, and
stimulate circulation Fundamentals of
Nursing by Kozier
and Erb, 8e

Avoid use of plastic

material. Remove Moistened
wet/ wrinkled linens Potentiates skin
promptly breakdown

Fundamentals of
Nursing by Kozier
and Erb, 8e

Provide Optimal
nutrition, including To provide with a
vitamins and positive nitrogen
increase protein balance to aid in
intake skin/ tissue
healing and to
maintain general
good health

Fundamentals of
Nursing by Kozier
and Erb, 8e
Promote Assist client to learn To control the
wellness stress reduction and feeling of
alternate therapy helplessness and
deal with situation
Fundamentals of
Nursing by Kozier
and Erb, 8e