A NURSING CARE PLAN Date and Time 5%

Promptness 5%
Cues & Needs 15%
IN PARTIAL FULFILLMENT OF THE Diagnosis 15%
REQUIREMENTS IN Goal of care 10%
PHC-RLE Interventions 40%
Evaluation 5%
Bibliography 5%

SUBMIITED TO:
Mr. Jerry Bedaňa, R.N.
Clinical Instructor

SUBMIITED BY:
Paul Ian Quindoy, St.N

DATE:
October 27, 2006
Name: Luna, Geraldo Room and bed #: 309-2 San Lorenzo Ward
Age: 34yrs. Old Attending Physician: Dr. Quitain
Chief complaint: multiple abrasions
Diagnosis: acute injury secondary to vehicular accident

DATE & CUES NEED NURSING DIAGNOSIS GOAL OF CARE NURSING INTERVENTION EVALUATION
TIME
October 27, S: Health High risk for infection At the end of my 1. Assess vital signs October 27, 2006,
2006 7:00 -“daghan kaayo Maintenance/ related to the presence of 1 day span of ®To obtain baseline data. 3:00pm @ 7-3 shift.
am @7-3 ko ug samad sa Health multiple abrasions at face, care, my patient 2. Assess and document skin
shift lawas.” Perception elbows and knees. will prevent conditions around abrasion sites. Goal met,
infection as ®For observation of signs of After my 1 day span of
evidenced by: infection. care patient is
3. Note for signs and symptoms prevented infection as
O: ® Before a person can - Absence of systemic infection. evidenced by:
-Vehicular become infected, signs and ®To prevent further skin damage
accident patient microorganisms must enter in symptoms of and complications. -absence of signs and
-Warm skin the body. The skin serves as systemic 4. Observe for localized signs of symptoms of systemic
around abrasion the first line of defense infection (fever infection at the incision site. infection.
and avulsion site against the pathogens; and chills). ®Patient with skin opening is at -absence of
-Flushed skin at however any breaks in the -Absence of risk for infection, so assessment complication
wound site integument can readily be a complication. is needed. -Abrasions are starting
-Moist dressing portal of entry. If the body of -Facilitate wound 5. Provide regular dressing care. to dry.
-Medication of the host’s immune system healing ®Reduces the risk for skin
Flammazine as cannot combat the invading complication and cross
ordered organism adequately, an contamination.
infection occurs. 6. Monitor medication and note Evaluated by:
patient’s response.
Bibliography: ®To determine the effectiveness
Gularick, Meg. PhD, Rn, et of the medication and if the Paul Ian Quindoy
al. Nursing Care Plans. medication has side effects. St.N
Mosby, Inc. 5th ed. ©2003 7. Discuss with patient proper
hygiene.
®Proper hygiene facilitates
wound healing.
8. Encourage to increase oral
fluid intake.
® Increase fluid intake aids in
wound healing.
9. Encourage to eat foods rich in
protein and fruits.
®Protein and ascorbic acid is
essential for wound healing.
10. Change linens as regular as
possible.
®Moisture provides good
breeding ground for
microorganisms changing linens
prevents cross contamination and
risk for infection.