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    Mark Norriel Celis

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    Mark Norriel Cajandab
    The patient, a 65-year-old male, presented with wounds on his arms and legs caused by mechanical factors like shearing forces, as evidenced by destruction of the epidermis. His long and dirty fingernails, body odor, and flaky skin also indicated poor hygiene likely due to inability to care for himself in his dirty environment. The nursing care plan involved teaching the patient proper wound care and hygienic measures to improve skin integrity and self-care abilities through lifestyle changes like maintaining short, clean nails. The expected outcomes were timely wound healing, ability to care for himself, and maintenance of proper hygiene.

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    Mark Norriel Celis

    Uploaded by

    Mark Norriel Cajandab
    29 views2 pages
    The patient, a 65-year-old male, presented with wounds on his arms and legs caused by mechanical factors like shearing forces, as evidenced by destruction of the epidermis. His long and dirty fingernails, body odor, and flaky skin also indicated poor hygiene likely due to inability to care for himself in his dirty environment. The nursing care plan involved teaching the patient proper wound care and hygienic measures to improve skin integrity and self-care abilities through lifestyle changes like maintaining short, clean nails. The expected outcomes were timely wound healing, ability to care for himself, and maintenance of proper hygiene.

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    mark norriel celis

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    The patient, a 65-year-old male, presented with wounds on his arms and legs caused by mechanical factors like shearing forces, as evidenced by destruction of the epidermis. His long and dirty fingernails, body odor, and flaky skin also indicated poor hygiene likely due to inability to care for himself in his dirty environment. The nursing care plan involved teaching the patient proper wound care and hygienic measures to improve skin integrity and self-care abilities through lifestyle changes like maintaining short, clean nails. The expected outcomes were timely wound healing, ability to care for himself, and maintenance of proper hygiene.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    29 views2 pages

    Mark Norriel Celis

    Uploaded by

    Mark Norriel Cajandab
    The patient, a 65-year-old male, presented with wounds on his arms and legs caused by mechanical factors like shearing forces, as evidenced by destruction of the epidermis. His long and dirty fingernails, body odor, and flaky skin also indicated poor hygiene likely due to inability to care for himself in his dirty environment. The nursing care plan involved teaching the patient proper wound care and hygienic measures to improve skin integrity and self-care abilities through lifestyle changes like maintaining short, clean nails. The expected outcomes were timely wound healing, ability to care for himself, and maintenance of proper hygiene.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    ASSESSMENT NURSING SCIENTIFIC PLANNING IMPLEMENTATION SCIENTIFIC EVALUATION

    DIAGNOSIS EXPLANATION RATIONALE


    Subjective data: Impaired Skin Integrity Alfrido 65yrs old Discharge Outcome: Independent: Outcome Achieved
    "Nagkakasugat-sugat related to mechanical Male After 2days of nursing Evaluate client with To identify risk for
    nalang yan, dahil yata factors (shearing forces) Intervention the patient impaired cognition, injury/ safety Wounds are treated
    sa marumi dito" as as evidenced by will be able to demonstrate developmental delay, need requirements. and patient gain
    verbalized by the destruction of epidermis Mechanical proper wound care. for use of restraints. knowledge about
    patient. specifically on the arms factors(shearing forces)
    simple wound care
    Objective data: and legs Short term outcome: Determine degree/ damage
     Wound and After 1wk of nursing of Integumentary To document status/ and hygienic
    scars on the Wound on the upper intervention the patient specifically epidermis(the provide baseline. measure.
    arms and legs. and lower extremities will be able to display damage upon)
     Destruction of specifically on arms timely healing of skin
    epidermis and legs. (wounds) without Keep the area clean/dry, To assist body's natural
    specifically on complication. carefully dress wound. process of repair.
    arms and legs.
     Temp 36.5 Demonstrate about simple To educate and in order
    degree celsius destruction of epidermis wound care/ wound to be aware on proper
    dressing. treating of wound.

    Health Teachings regarding To provide knowledge


    Impaired Skin Integrity proper hygiene like proper in proper hygiene and
    hand washing. treatment on wounds.

    Collaborative: For faster healing and


    Diet: intake of food rich in nutritional requirement.
    vitamin C and nutritious
    food.
    NURSING CARE PLAN

    ASSESSMENT NURSING SCIENTIFIC PLANNING IMPLEMENTION SCIENTIFIC EVALUATION


    DIAGNOSIS EXPLANATION RATIONALE
    Objective data: Self-care deficit: poor Alfrido 65 yrs old Discharge Outcome: Independent: Outcome Achieved
     Long and dirty hygiene related to Male After 1 week of Initiate nurse patient To establish rapport
    inability to maintained intervention the client relationship and gain client The client will be able to
    finger nails
     Looks weak proper hygiene as will be able to cooperation and trust. demonstrate lifestyle
    and tired evidenced by dirty and Inability to maintain demonstrate lifestyle changes to meet self-
     Obvious body long finger nails and proper hygiene changes to meet self- Explain the task in short, A complex task will be care needs as evidenced
    odor obvious body odor care needs as evidenced simple steps after easier for the client if
     Flakes was by of maintaining of identifying concern it is broken down into by clean and short finger
    observed and Dirty and long finger hygiene and clean nails series of steps. nails, and no noted body
    some cerumen nails and obvious body Short term Outcome: Encourage the patient to Performing self-care odor, knows the
    was noted. odor After 8 hours of participate actively in activities enhances to important of hygienic
    intervention the client self-care activities as maintain proper
    will be able to much as possible. hygiene. measures by
    Overcrowded and dirty verbalized the maintaining proper and
    environment importance of self-care Cut the normal thickness Long nails harbors well groomed
    activities. of nails, toenails clipper microorganism personality.
    and using the curve of the maintaining it shorts
    Self-care Deficit toe as guide. and clean prevent
    contamination.
    Health Teachings about In able to gain
    proper hygiene, and knowledge in
    hygienic measures. maintaining proper
    hygiene to prevent
    disease.
    Collaborative For nutritional and
    Diet; intake of nutritious metabolic requirement.
    food and rich in vitamins.

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