NURSING CARE PLAN

Assessment

Nursing Diagnosis

Analysis

Objective:
- Presence of
rashes on the
lower
extremities
- Edema on
lower
extremities

Impaired
skin
Integrity related
to Inflammation

Inflammation
in
the small blood
vessels
as
manifested
by
rashes
and
edema resulting
to impaired skin
integrity.

Objectives

Nursing
Intervention

After 7 hours of
Provided
nursing
protective
interventions the
measures by:
client will be able 1. keeping area
clean and dry,
to display
carefully address
improvement of
rashes and
skin integrity as
edema; and
evidenced by
intact skin.
2. Avoiding or
limiting use of
plastic material.
Remove wet and
wrinkled linens
promptly.
Collaborative:
Administered
Cefuroxime 550
mg/IV as
prescribed by the
physician.

Rationale

Evaluation

After 7 hours of
nursing
1. To assist bodys interventions the
natural process of client was able to
display
repair and
improvement
of
prevent any
skin integrity as
further
evidenced
by
complications
intact skin.
such as infection
from occurring.
2. Moisture
potentiates skin
breakdown

Cefuroxime is
indicated to
maintain normal
skin and skin
structure.

NURSING CARE PLAN

Assessment
Subjective:
- Verbal report of
weakness and
pain (4/10) on
the left lower
extremity

Objective:
- Prolonged bed rest
- Imposed activity
restriction

Nursing Diagnosis

Analysis

Objectives

Nursing
Intervention

Impaired mobility
related to
weakness, pain,
prolonged bed
rest and imposed
activity restriction

Presence of pain
on the lower left
extremity
resulting to
impaired mobility.

After 7 hours of
nursing
intervention, the
client will be able
to perform
optimum
mobilization.

1. Discussed the
importance of
ambulation
through role play.
2. Assisted in
ambulating.
Collaborative:
1. Administered
Paracetamol PRN
as ordered by the
physician.

Rationale

1. To establish
knowledge base
within the
patients
understanding
capacity.
2. To promote
mobility.

Paracetamol is for
pain relief.

Evaluation

After 7 hours of
nursing
interventions the
client was able to
perform
mobilization.

NURSING CARE PLAN

Assessment

Nursing Diagnosis

Analysis

Subjective:
Ate, mawawala din
po ba ito (rashes)
agad? Kasi
sasayaw po ako sa
school namin eh.
as verbalized by
the client.

Body image
disturbance
related to skin
rash

Inflammation as
evidenced by
rashes and
edema has
altered the
integrity of the
skin resulting to
psychological
effect on the
patient about her
body image.

Objective:
- restlessness due
to anxiety

Objectives

Nursing
Intervention

After 7 hours of
nursing
intervention, the
patient will be
able to regain
high levels of selfesteem as
evidenced by:
1. Acknowledged
and accepted
1. verbalization of expression of
acceptance of
feelings of
self in situation;
frustration.
and

2. verbalization
of positive selfconcept.

Rationale

1. Acceptance of
this feeling as a
normal response
to what has occur
facilitates
resolution.
2. To maintain
2. Encouraged
open lines of
family interaction communication
with each other
and to provide
and with
ongoing support
rehabilitation
for patient and
team.
family.
3. Prepares
patient for
3. Role play social reaction of others

Evaluation

After 7 hours of
nursing
interventions the
client was able to
perform
mobilization.

situation of
concern to
patient.
4. Encouraged
patient to look at
or touch affected
body part.

and anticipates
way to deal with
them.
4. To begin to
incorporate
changes in body
image.

NURSING CARE PLAN

Assessment

Nursing Diagnosis

Analysis

Subjective:
Gising siya nang
gising tuwing gabi,
di siya makatulog
ng maayos. as
verbalized by the
mother.

Disturbed
sleeping pattern
related to pain

Presence of pain
causes
discomfort
leading to
disturbed
sleeping pattern.

Masakit po kasi
binti ko. as
verbalized by the
patient.
Objective:
- drowsiness as
manifested by
frequent yawning
- presence of dark

Objectives

After 1-2 days of

nursing
intervention, the
patient will be
able to regain
normal sleeping
pattern as
evidenced by:
1. verbalization of
pain relief;
2. verbalization of
sleep satisfaction;
and
3. absence of

Nursing
Intervention

Collaborative:
Administered
Paracetamol PRN
as ordered by the
physician.

Rationale

Evaluation

Paracetamol is for After 1-2 days of

pain relief.
nursing
intervention, the
patient was able
to regain normal
sleeping pattern
as evidenced by:
1. verbalization of
pain relief;
2. verbalization of
sleep satisfaction;
and
3. absence of
dark circles

circles around the

eyes

dark circles
around the eyes.

around the eyes.

Prepared by: RLE 2 of 2 NUR 6

Submitted to: Sir Les Paul Valdez
Date: March 13, 2014
THANK YOU SIR!!