VI.

NURSING CARE PLAN

NURSING CARE PLAN #1

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective cues: Acute pain r/t Short term: Independent Short term:
sakit jud siya sacral ulcer Encouraged to >promote
permi labaw After 8 hours of do deep relaxation, help Patient
maglihok nursing breathing reduce pain participated in the
as verbalized by intervention; regimen as
the patient Patient Instructed to >reduces evidence by:
demonstrate turn side to pressure on the doing deep
participation on side and ulcer site and breathing
the therapy/ assume provide comfort positioning himself
regimen comfortable and turning to
Objective cues: position as sides
>pain score of 6 preferred
out of 10
>grimacing upon
moving Instructed to
>moves slowly Long term: have >to divert attention Long term:
>needs divertional from pain Pain still didnt
assistance upon After 16 hours of activities such subside with a
moving nursing as: listening Pain score of 6/10
intervention; music, talking
Pain score will to S.O,
gradually reduce watching
up to 3 out of 10 favorite t.v
shows/movies

>promote

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 Provided relaxation
conducive,
quiet
environment;
dim lights and
comfortable
temperature
>to conserve
Provided energy since
adequate rest situation is
periods stressful as well

Collaborative
Administered
Tramadol >help relieve pain
500mg, 1tab
as prescribed
by the
physician

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 NURSING CARE PLAN #2

ASSESSMENT DIAGNOSI PLANNING IMPLEMENTATION RATIONALE EVALUATION

S
Subjective cues: Impaired Short term: Independent Short term:
As questioned for skin integrity Assisted on the > proper wound
any back r/t After 8 hours of wound dressing dressing promote S.O follows all
problems: debridement nursing healing the instructed
Patient verbalized, secondary intervention; Instructed S.O to activities and
wala pero kato ra to sacral Patient S.O turn patient side to >disperse pressure really participate
akong samad ulcer will demonstrate side every 2hrs and to decrease in the regimen
salikod understanding of tissue load
the importance of
proper wound Maintained head of >prevent further
care bed at lowest occurrence
Reduced risk elevation pressure ulcer
of further
impairment of Monitored and kept >prevent infection
skin integrity dressing dry and
intact
Long term:
Long term: Kept linens clean >prevent infection
and dry Patient still needs
objective cues: After 2 days of to undergo
>ulcer on the nursing Explained debridement but
sacral area intervention; importance of proper >promote shows
>has a colostomy Patient shows wound care and the compliance improvement as
on the abdomen improvement and importance of the stated by the
> S/P healing of ulcer intervention physician
debridement

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Collaborative
Ask S.O to
collaborate and let
them involve or be >to establish good
more hand on in the support system
regimen of the
patient

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 NURSING CARE PLAN #3

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective cues: Ineffective Short term: Independent Short term:

dugay gaka ayo Peripheral Assist client in >to enhance
ang akong Tissue At the end of 8 hours frequent venous return Only minimal
samad, as Perfusion of nursing edema on both
ambulation, when
verbalized related to interventions, the feet was
increased patient will be able to: possible present. Patient
blood 1. Verbalize >to promote has still a slow
viscosity understanding of Elevate legs peripheral healing of sacral
secondary to condition, therapy when sitting: circulation ulcer but is
hyperglycemi regimen, side avoid sharp already closed
a effects of angulation of the and sutured.
medications and hips or knees
when to contact >to increase
Objective cues: healthcare Elevate the head gravitational
>increased Hgt provider. blood flow
of bed
level: 252 mg/dl 2. Demonstrate
(Aug 5,16 reading) increased
>Skin color: pale perfusion; reduce >It restricts
> Edema on edema Discourage sitting circulation and
both feet 3. Decrease blood or standing for leads to
>Slow healing glucose level extended periods venous stasis
on sacral ulcer from 252 mg/dl to of time, wearing and edema
normal range 80-
constrictive
110 mg/dL
4. Improve skin clothing or
color at the crossing legs
wound site when seated >protein

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 promotes
Long term: Encouraged to faster healing Long term:
increase food of the wound
At the end of 2days of intake rich in Patient was
nursing interventions, able to
proteins such as
the patient will be able demonstrate
to: beans, fish, eggs behaviors and
1. Demonstrate and seafood lifestyle to
behaviors and improve
lifestyle Collaborative circulation
changes to Administer however
improve minimal edema
medications as
circulation >helps in on both feet is
2. Completely ordered by the lowering blood still present.
eliminate physician glucose level Hgt level: 154
presence of mg/dl
edema at lower NovoMix >to promote (Aug 8,16 reading)
extremities (Insulin Aspart), 6 faster healing
3. Maintain normal units, STAT (6:20 PM), of the wound
blood glucose SQ
level of 80-110 Potassium Cholride
mg/dL
(Kaligen), 5mm
mg/1tab TID, (8am,
1pm, 6pm,)

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 NURSING CARE PLAN #4

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective cues: Impaired Short term: Independent Short term:

karon dili nakaayo physical
ko makalihok2 as mobility r/t After 3 hours of Encouraged patient to >increases self- Patient is so
verbalized by the pain nursing participate in the esteem positive and tries
patient intervention; regimen to really do things
Patient will on his own
demonstrate Positioned patient >promote comfort
participation in properly as desired
the regimen and
verbalize ways
on how to help
self with the Encouraged patient to > help self tolerate
limitation increase level of moving by doing it
motion as tolerated slowly and by the Long term:
time by time increasing level of
objective cues: motion Patient tries to
>patient lying bed Long term: shift position on
all the time Instructed to maintain
After 8 hours of adequate nutritional > to help his own
> needs assistant nursing strengthen body
upon moving status

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intervention;
Patient acts Emphasized the
the identified importance of the > promote
ways to help self regimen compliance
with the
limitation

Collaborative >To build a good

Let the supporting support system
others assist the and to include the
patient in doing the s.o in the regimen
regimen

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 NURSING CARE PLAN #5

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective cues: Readiness Short term: Independent Short term:

dapat gyod gina for Verify clients level of >provides opportunity
maintain ang enhanced At the end of 6 understanding of to assure accuracy Patient is able to
kahinlo maam aron self care hours of nursing therapeutic regimen. and completeness of demonstrate
wala poy samot manageme- interventions, the Note specific goals. knowledge base for techniques and
complication as nt related to patient will be able future learning lifestyle changes to
verbalized by the infection to: meet self-care
patient control 1. Demonstrate Assist patient to >the ability to perform needs
techniques and identify self-care self-care activities is
lifestyle activities influenced by disease
changes to activity
meet self-care
needs Promote significant >to promote wellness
others involvement in
planning and
implementing added
tasks and
Objective cues: Long term: responsibilities Long term:
>shows positivity

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towards the At the end of 2 days Provide health >aids in patient fast Patient is able to
treatment of nursing teachings such as: recovery and prevent perform self-care
>appropriate interventions, the complications activities within level
choices of daily patient will be able -emphasize the of own ability; is
activities for to: importance of proper now independent in
meeting the goals of 1. Perform self- hygiene by taking terms of feeding but
a treatment care activities bath daily and proper still needs
within level of hand washing assistance in
own ability -proper daily wound performing other
care activities
-medication
compliance
-increase food intake
rich in protein

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