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    College of Nursing and Allied Medical Sciences: Wesleyan

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    Charie Ocampo
    The nursing care plan summarizes a 50-year-old patient with a spinal cord injury who has developed a grade 2 pressure ulcer on his lower back. The plan involves monitoring the ulcer daily, keeping the area clean and dry, and turning the patient every 2 hours to reduce pressure and risk of further skin breakdown. Nutritional support is also emphasized to aid healing. The short-term goal is reducing risk of impairment within 6-8 hours, while the long-term goal is healing the ulcer and regaining skin integrity within 3-4 days.

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    College of Nursing and Allied Medical Sciences: Wesleyan

    Uploaded by

    Charie Ocampo
    118 views3 pages
    The nursing care plan summarizes a 50-year-old patient with a spinal cord injury who has developed a grade 2 pressure ulcer on his lower back. The plan involves monitoring the ulcer daily, keeping the area clean and dry, and turning the patient every 2 hours to reduce pressure and risk of further skin breakdown. Nutritional support is also emphasized to aid healing. The short-term goal is reducing risk of impairment within 6-8 hours, while the long-term goal is healing the ulcer and regaining skin integrity within 3-4 days.

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    NCP

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    The nursing care plan summarizes a 50-year-old patient with a spinal cord injury who has developed a grade 2 pressure ulcer on his lower back. The plan involves monitoring the ulcer daily, keeping the area clean and dry, and turning the patient every 2 hours to reduce pressure and risk of further skin breakdown. Nutritional support is also emphasized to aid healing. The short-term goal is reducing risk of impairment within 6-8 hours, while the long-term goal is healing the ulcer and regaining skin integrity within 3-4 days.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    118 views3 pages

    College of Nursing and Allied Medical Sciences: Wesleyan

    Uploaded by

    Charie Ocampo
    The nursing care plan summarizes a 50-year-old patient with a spinal cord injury who has developed a grade 2 pressure ulcer on his lower back. The plan involves monitoring the ulcer daily, keeping the area clean and dry, and turning the patient every 2 hours to reduce pressure and risk of further skin breakdown. Nutritional support is also emphasized to aid healing. The short-term goal is reducing risk of impairment within 6-8 hours, while the long-term goal is healing the ulcer and regaining skin integrity within 3-4 days.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    WESLEYAN

    AN AUTONOMOUS METHODIST UNIVERSITY

    COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES


    NURSING CARE PLAN
    NAME OF CLIENT: Juan DC DIAGNOSIS: Spinal cord injury
    AGE: 50

    ASSESSMENT NURSING Nursing Goal Nursing Intervention RATIONALE EVALUATION


    DIAGNOSIS

    Subjective Data: Impaired Skin Short term: After 6 to 8 Indepenpent: 1. It developed trust Attainment/progress
    Integrity hours of nursing 1. Establish rapport. to improve patient toward desired
    “mahapdi at nag Related to pressure interventions, the client 2. Monitor vital signs. care. outcomes
    susugat ang bandang ulcer secondary to will: Have reduced risk 3. Tilt or turn client from
    pwetan ko” as prolonged immobility of further impairment of side to side every 2 2.to have a baseline
    verbalized by the as evidenced by skin integrity hours. data
    patient pain, bleeding, 4. Inspect and monitor
    redness, wound site of skin impairment at 3.Avoid additional
    Method: Interview drainage. least once a day for color skin ulcer
    changes, redness,
    Objective Data Long Term: swelling, 4. Systematic
    After 3-4 days of Warmth, pain, or other inspection can
    Vital signs: nursing interventions, signs of infection. identify impending
    Bp: 120/80 the client will: Determine whether the problems early
    Rr: 20 client is experiencing
    Pr: 95 • Experience changes in sensation 5. Cleansing should
    Temp. 36.5 healing of ulcer/regain Or pain. Closely assess not compromise
    skin integrity (reduce high-risk areas such as the skin
    • Presence of size of ulcer) bony prominences,
    grade 2 pressure • Reduce risk for skinfolds, the sacrum, 6. This technique
    ulcer on the lumbar infection and reduces the risk of
    area. Heels. infection in
    5. Monitor the client’s impaired tissue
    • Disruption of skin care practices, integrity.
    WESLEYAN
    AN AUTONOMOUS METHODIST UNIVERSITY

    COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES


    skin surface noting type of soap or
    (epidermis) other cleansing agents 7. Wound infections
    used, temperature may be managed
    Braden of water, and frequency of well and more
    Scale: High risk skin cleansing. efficiently with
    topical agents,
    Method: Inspection 6. Keep a sterile dressing although
    technique during wound intravenous
    care. antibiotics may be
    indicated.
    Dependent:
    8. To prevent
    7. Administer antibiotics malnutrition &
    as ordered. delayed healing
    9. To promote wound
    8. Ensure adequate healing on clients
    dietary intake. Review who do not have
    dietician’s adequate calories.
    recommendations. 10. To prevent
    contamination/spr
    9. Supplement the diet ead of infection
    with vitamins & minerals.
    Vitamins C and zinc are 11. to secure the
    commonly prescribed. result

    10.  Prevent the ulcer 12. Meeting


    from being exposed to nutritional needs
    urine & feces. Use of the client is
    indwelling catheters, important to
    bowel containment prevention of skin
    systems. breakdown as well
    as preventing
    WESLEYAN
    AN AUTONOMOUS METHODIST UNIVERSITY

    COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

    Collaborative: 13. Complications


    of illness.
    11. Collaboration with Adequate nutrition
    radiology department, for is important for
    the result of diagnostic maintaining overall
    exams homeostasis and
    health
    12. Assess the client’s
    nutritional status; refer
    for a nutritional consult,
    and/or institute dietary
    supplements.

    Name of Student: Charie Rose L. Ocampo Prof. Jan Rainier Balaria


    Year/Block # 4-1 Name of Instructor

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