Assessment

O:
(+) foot
ulcer @ L
foot
reddish
pink
open
rupture
Dry and
shallow
wound
Stage II A partialthickness
loss of
skin
involving
epidermi
s and
dermis.
-

Nursin
g
diagno
sis
Impaire
d
skin
integrity
related
to
pressur
e ulcer

Backgrou Planning
nd of the
study

Intervention

Pressure
ST:
Independent:
ulcers, also After 6 to 8 hours
known as
nursing intervention
1. Assess between
pressure
the client will be able
folds of skin, use
sores,
to
a mirror to see the
bedsores
heels. Also
and
Have reduced
assess under
decubitus
oxygen tubing
further skin
ulcers, are
especially on the
impairment of
localized
ears & the cheek,
skin integrity.
injuries to
and under
the skin
medical devices.
Patients
and/or
caregiver will
underlying
2. Note objective
be able to
tissue that
data of pressure
demonstrate
usually
ulcer (stage,
understandin
occur over
length, width,
g and skills in
a bony
depth, wound bed
care of wound
prominence
appearance,
as a result
drainage &
LT:
of pressure,
condition of
After 2 days
or pressure
periulcer tissue)
of nursing
in
intervention
combinatio
3. Increase the
the client will
n with
frequency of
be able to
shear
turning (turning
reduced risk
and/or
q2). Position the
for infection.

Rationale

1. Pressure ulcers
under medical
devices are
commonly
overlooked.

2. Reassessment of
ulcer is completed
each time dressing
are changed or
sooner if ulcer shows
manifestations of
deterioration.
Analyses of the
trends in healing are
important step in
assessment.
3. To disperse pressure
over time or

Evaluation

ST:
After 6 to 8 hours
nursing intervention
the client is able to
Have reduced
further skin
impairment of
skin integrity.
Patients
caregiver will
be able to
demonstrate
understandin
g and skills in
care of wound

ACTI

LT:
After 2 days of
nursing intervention
the client is able to
reduced risk for
infection.

friction.

client to stay off

the ulcer. If there
is no turning
surface without a
pressure ulcer,
use a pressure
redistribution bed
& continue turning
the client
4. Elevate heels off
the bed by using
pillows or heel
elevation botts.
5. Maintain head of
bed @ the lowest
elevation, if client
must have the
head elevated to
prevent
aspiration,
reposition to 30
degree lateral
position. Use seat
cushions &
assess sacral
ulcers daily.
6. Follow body
substance
isolation

decreasing the
tissue load

4. Heel covers do not

relieve pressure, but
they can reduce
friction.
5. To prevent further
occurrence of
pressure ulcer.

6. To reduce risk of
infection

precautions; use
clean gloves &
clean dressing for
wound care.
Practicing proper hand
washing before & after
wound care.

Dependent/Collaborate
:
7. Ensure adequate
dietary intake.
Review dieticians
recommendations
.
8. Prevent the ulcer
from being
exposed to urine
& feces. Use
indwelling
catheters, bowel
containment
systems, & topical
creams or
dressings.
9. Supplement the

7. To prevent
malnutrition &
delayed healing
8. To prevent
contamination/sprea
d of infection

9. To promote wound
healing on clients
who do not have
adequate calories.
Pressure ulcers
cannot heal in clients
with severe
malnutrition.
To promote faster

diet with vitamins

& minerals.
Vitamins C and
zinc are
commonly
prescribed.

Assessment

Nursing
diagnosis

Background
study

Planning

O:

Impaired physical
mobility related to
neuromuscular
damage
involvement

Neuromuscular
diseases are
those that affect
the muscles
and/or their direct
nervous system
control, problems
with central
nervous control
can cause either
spasticity or some
degree of
paralysis (from
both lower and
upper motor
neuron disorders),
depending on the
location and the
nature of the
problem.

ST:

slowed
movement
Limited
range of
motion
(ROM)
Functional
level: level
2-requires
help from
another
person

ACTI

healing & reduce

infection

Nursing
intervention

1. Monitor V/S

Rationale

1. To note

Evaluation

ST:

After 8 hours, of

changes

After 8 hours, of

nursing

and for

nursing

intervention the

baseline

intervention the

client will be able

comparison. client is able to

to shows

2. Determine the

shows

understanding

diagnosis that

2. To be

understanding

situation or risk

contributes to

informed

situation or risk

factors and

immobility

about the

factors and

individual

situations

individual

treatment regimen

that may

treatment regimen

and safety

restrict

and safety

measures

movements

measures

3. Encourage
LT:
After 2 days of

and facilitate

3. The longer

LT:
After 2 days of

nursing

early

the patient

nursing

intervention the

ambulation

remains

intervention the

client will be able

and other

immobile

client will be able

to show ,effective

ADLs when

the greater

to show ,effective

and collaborative

possible.

the level of

and collaborative

nursing

Assist with

debilitation

nursing

interventions,

each initial

that will

interventions,

patient will

change:

occur

patient will

maintain position,

dangling,

maintain position,

function and skin

sitting in chair,

function and skin

integrity

ambulation

integrity

4. Perform
passive or

4. Exercise

active ROM

promotes

exercises to

increased

all extremities

venous
return,
prevents
stiffness,
and
maintains

muscle
strength
5. Turn and
position every

and
endurance

2 hours or as
needed.

5. This
optimizes
circulation
to all
tissues and

6. Provide safety
measures(sid

relieves
pressure.

e rails, using
pillow to

6. To provide

support body

safety and

part)

reduce the
risk of
pressure
ulcers

7. Massage back
and bony
prominences

7. It provides
comfort to
the patient
and
promotes
good
circulation
Independent
8. Consult with
physical or
occupational
therapist as
indicated

8. To develop
individual
exercise
therapy or
program

Assessment

O:
-client has
tracheostomy on
the neck region
-client is
connected
to an
oxygen
therapy
via venturi
mask 8-10
lpm
-difficulty
in
expressin
g thoughts
verbally
-difficulty
in use of

Nursing
diagnosis

Backgrou
nd study

planning

Impaired
verbal
communication
related to oral
muscle tone
control and
tracheostomy
procedure

Decreased,
delayed, or
absent
ability to
receive,
process,
transmit,
and use a
system of
symbols

After 2 hours of
nursing interventions
the client will
establish method of
communication in
which needs can be
expressed.
As evidence by:
Established
eye contact
while
communicatin
g with others
use paper and
pen to express
needs

Intervention

1. Monitored vital
signs with
emphasis to
BP.
2. provided an
atmosphere of
acceptance
and privacy
through
speaking
slowly and in a
normal tone,
not forcing the
client to
communicate
3. Taught
techniques to
improve
speech by
initially asking
questions that
client can
answer with a
"yes" or "no".

Rationale

1. Establishes
baseline data
for review of
existing
conditions.
2. Impaired ability
to
communicate
spontaneously
is frustrating
and
embarrassing.
Nursing
actions should
focus on
decreasing the
tension and
conveying an
understanding
of how difficult
the situation
must be for the
client.
3. Deliberate
actions can be

Evaluation

After 2 hours of
nursing interventions
the client will
establish method of
communication in
which needs can be
expressed.
As evidence by:
Established
eye contact
while

ACTI

communicating
with others
use paper and
pen to express
needs

facial and
body
expressio
n

4. used strategies
to improve the
client's
comprehensio
n by using
touch and
behavior to
communicate
calmness and
adding other
non-verbal
methods of
communication
such as using
flash cards for
basic needs;
using paper
and pen

5. involved the
relatives in the
plan of care
educate relatives to
establish a method of
communication
through sign
language

taken to
improve
speech. As the
speech
improves, his
confidence will
increase and
she will make
more attempts
at speaking.
4. Improving the
clients
comprehensio
n can help to
decrease
frustrations
and increase
trust. Clients
with aphasia
can correctly
interpret tone
of voice.
5. Enhances
participation
and
commitment to
plan.
Imparts thought and
answers the needs of
the client with
lessened difficulty.

Assessment
O:
-(+)presence of
wound
-v/s taken

Nursing
diagnosis
Risk for infection
related to wound in
the calcaneal
surface of the left
foot

Background
study
Infection is the
invasion of an
organism's body
tissues by diseasecausing agents,
their multiplication,
and the reaction of
host tissues to
these organisms
and the toxins they
produce. Infectious
disease, also
known as
transmissible
disease or
communicable
disease, is illness
resulting from an
infection.

Planning

Intervention
1. Note risk factor for
occurrence of
infection

After 8 hrs of
nursing intervention
the patient will be
able to:
a.)
Identify
interventions to
prevent/reduce risk
of infection

2. Observe for
localized signs of
infection
.

b.)
Achieve
timely wound
healing; be free of
purulent drainage or
erythema;

3. Stress proper
hand-hygiene by
all caregivers bet.
Therapies/clients.

c.)
Be afebrile
as evidenced by the
normal V/S.

4. Recommend
routine or body
shower/scrub
when indicated
5. Change surgical or
other wound
dressings, as
indicated, using
proper technique
for changing or
disposing of
contaminated
materials
6. Review individual
nutritional needs,

Rationale

Evaluation

1. To assess
causative/
contributing
factors

After 8 hrs of
nursing intervention
the patient is able
to:

2. To assess for
infected sites

a.)
Identify
interventions to
prevent/reduce risk
of infection

3. A first line
defense
against
healthcareassociated
infections

b.)
Achieve
timely wound
healing; be free of
purulent drainage or
erythema;

Risk

c.)
Be afebrile
as evidenced by the
normal V/S.
4. To reduce
bacterial
colonization

5. To prevent
infection

6. To promote
wellness.

Assessment

Nursing
diagnosis

Background
study

Planning

O:
-decrease
strength in lower
extremities

Risk for falls

related to
unsecured side
rails

A fall is defined as
an event which
results in a person
coming to rest
inadvertently on
the ground or floor
or other lower
level.

Within 2 to 3hours
of rendering
proper nursing
intervention, the
patient will be free
from fall.

-weak in
appearance

Intervention

1. Identify
factors that
affect safety
needs.

2. Assess the
patient
ability to
ambulate
safely with
or without
assistive
devices.

Rationale

1. To know the
intervention
that will be
established.

Evaluation

Within 2 to 3hours
of rendering
proper nursing
intervention, the
patient will be free
from fall.

2. It is helpful to
determine
the
clients functional
abilities

3. Thoroughly
orient the
patient to
environment
.

3. to plan for
ways of
improving the
problem
areas

4. Assess
vision and
provide

4. For the client

to familiarize

Risk

adequate
lighting to
clearly
seethe
pathway.

5. Ask the
significant
others to
always stay
with the
client.

6. Instruct the
patient to
call for
assistance
when
moving.

7. Put side
rails.

the
surroundings
.

5. To provide
well-lighted
environment
and avoid the
occurrence
of injury.

6. To ensure
clients safety.

7. To prevent
the patient
from falling
on bed

Assessment

Nursing
diagnosis

Background
study

Planning

O:

Risk for impaired

skin integrity
related to prolong
bed rest

Skin is the
primary defense
of the body; it
protects the body
against infections
and diseases
brought about by
the invasion of
microbes in the
body. A normal
skin is moist and
intact; dryness of
the skin is more
prone to friction
that may result to
impairment of the
skin integrity as
compared with a
moist skin.

Within 2 to 3hours
of rendering
proper nursing
intervention, the
patient will be free
from having
infection.

physical

immobilizatio
n
Presence of
grade 1
pressure ulcer
on the lumbar
area.
Disruption of
skin surface
(epidermis)

Intervention
1. Assess skin

routinely
noting
moisture,
color and
elasticity
review with
client /SO
history of
past skin
study.
2. Note

presence of
conditions
or situation

Rationale
1. May

indicate
particular
vulnerability

4. Provide

protection
by use of
pads pillows
foam
mattresses
water bed
and so forth
5. Remove

wet and
wrinkles
linens

Within 2 to 3hours
of rendering
proper nursing
intervention, the
patient will be free
from having
infection

2. That may

impair skin
integrity
3. Reduce like

hood of
progression
to skin
breakdown

3. Observed

reddened or
blanched
areas or
skin rashes
and institute
treatment
immediately

Evaluation

4. To increase

circulation
and limit or
eliminate
excessive
tissue
pressure

5. Moisture

potential
skin
breakdowns

Risk

A. Demographics (biographic Data)

Client Initial: R.C
Gender: Female

Health History

Age: 77 Year Old

Religion: Catholic
Occupation: None
Usual source of income: Clinic and Hospital
Date of admission: January 6, 2016
Initial diagnosis: CVD (L) BLEED BASAL GANGLIA S/P CVD
Final: CVD (L) BLEED BASAL GANGLIA S/P CVD

NURSING CARE PLAN

DX: CVD (L) BLEED BASAL GANGLIA S/P CVD (2012)

Submitted By: Ylron John Tapar

Submitted To: Maria Veronica Doceo RN, MAN