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REPUBLIC of the PHILIPPINES

City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West `Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
_____________________________________________________________________________________
CENTER OF NURSING

NURSING CARE PLAN


Name: Prof. Maria Genina L. Siriban, RN
Section:

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation


Short-term Independent:
Subjective Impaired Skin Objective • Assess • Pressure ulcers Short-term
Cues Integrity between folds under medical Objective
related to pressure After 6-8 hrs of of skin, remove devices are After 8 hrs of
injury secondary to nursing anti embolic commonly nursing
Objective prolonged interventions of stockings or overlooked. interventions
Cues immobility and nursing devices & use a patient:
unrelieved pressure interventions, the mirror to see the •reduced
• Grade 2 client will: heels. Also risk of
Pressure injury assess under further
on sacral • Have reduced oxygen tubing impairment
decubitus risk of further especially on of skin
impairment of the ears & the integrity as
• Dry & shallow skin integrity cheek, and evidenced
wound under medical by no actual
•Patient’s s/o will devices. additional
• Reddish-pink demonstrate tissue
open/rupture understanding & • Note objective • Reassessment of breakdown
blister skill in care of data of pressure ulcer is completed & no
wound ulcer (stage, each time persistent
• Dry Skin length, width, dressing are reddened
Long-term depth, wound changed or sooner areas
•Edema Objective bed appearance, if ulcer shows
drainage & manifestations of
REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West `Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
_____________________________________________________________________________________
CENTER OF NURSING
After 3-4 days of condition of deterioration. •patient’s
nursing periulcer tissue) Analyses of the s/o
interventions, the trends in healing demonstrate
client will: are important step d
in assessment. understandi
• Experience ng & skill in
healing of •Increase the • To disperse care of
ulcer/regain skin frequency of pressure over wound
integrity (reduce turning time or
size of ulcer) (turning q2). decreasing the PARTIALLY
Position the tissue load MET
• Reduce risk for client to stay
infection off the ulcer. If Long-term
there is no Objective
turning surface After 4 days of
without a nursing
pressure ulcer, interventions
use a pressure the client:
redistribution
bed & continue •Experience
turning the d healing of
client tissue as
evidenced
•Elevate heels • Heel covers do by
off the bed by not relieve developmen
using pillows pressure, but they t of
or heel can reduce granulation
elevation botts. friction. tissue &
decrease in
•Maintain head • To prevent ulcer size.
of bed at the further
lowest
REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West `Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
_____________________________________________________________________________________
CENTER OF NURSING
elevation, if occurrence of •Reduce risk
client must pressure ulcer. of infection
have the head as evidenced
elevated to by
prevent observing
aspiration, proper hand
reposition to 30 washing
degree lateral technique
position. Use before &
seat cushions after wound
& assess sacral care.
ulcers daily.
PARTIALLY
•Follow body MET
substance • To reduce risk
isolation of infection
precautions;
use clean
gloves & clean
dressing for
wound care.
Practicing
proper hand
washing before
& after wound
care.

Dependent

• Prevent the ulcer


from being
exposed to urine
REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West `Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
_____________________________________________________________________________________
CENTER OF NURSING
& feces. Use • To prevent
indwelling contamination/spr
catheters, bowel ead of infection
containment
systems, &
topical creams or
dressings.

•Supplement the
diet with vitamins
& minerals.
Vitamins C and • To promote
zinc are wound healing on
commonly clients who do
prescribed. not have adequate
calories.
•Provide oral
supplementations,
tube-feedings or
hyperalimentation • Pressure ulcers
to achieve cannot heal in
positive nitrogen clients with
balance. severe
malnutrition.

•Remove
devitalized tissue
from the wound
bed, except in the
avascular tissue or •To promote
on the heels. faster healing &
Began by reduce infection
REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West `Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
_____________________________________________________________________________________
CENTER OF NURSING
cleansing the
ulcer bed with
normal saline,
then use
appropriate
technique for
debridement.
Once the ulcer is
free of devitalized
tissue, apply
dressing the keep
the wound bed
moist & the
surrounding skin
dry. Do not use
occlusive
dressings on
ulcer.

Collaborative

• Ensure adequate
dietary intake.
Review dietician’s
recommendations •To prevent
malnutrition &
delayed healing

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