Nursing Care Plan

Prioritization

a.

b.

c.

d.

e.
 Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Impaired skin The patient will Record Determining the The patient
integrity related to display intact skin observations baseline where displays intact
Sumasakit yung and skin tissue daily skin turgor, changes in status skin and skin
inflammatory dermal
balat ko, as after a series of circulation, and can be compared tissue and
and epidermal as
verbalized by the interventions sensory as well as and appropriate describes
evidenced by reddish
patient. before discharge other changes that intervention can measures to
and damaged
occur. be applied protect and heal
integumentary tissue
the tissue,
Objective: including wound
Assess the Pain is part of the care.
o Widespread skin patients level of normal
erythema distress. inflammatory
o Black and thick process. The
crust on the lips extent and depth
and mucous of injury may
membranes affect pain
o Inflamed sensations.
conjunctiva
o Painful Know signs of The patient who
widespread itching and scratches the skin
lesions scratching. in attempts to
o Reddish skin alleviate extreme
Vital Signs: itching may open
o T: 39.1 C skin lesion and
o P: 94 bpm increase risk for
o R: 17 bpm infection.
o BP: 140/90
mmHg
 Monitor patients Individualize plan
skin care is necessary
practices, noting according to
type of soap or patients skin
other cleansing condition, needs,
agents used, and preferences.
temperature of
water, and
frequency of skin
cleansing.

Use light clothing Reduce irritation

and soft looms. and pressure on
the seam line
dress, let the
lesion open up to
air to increase the
healing process
and reduce the
risk of infection.

Keep your loom. To prevent

infection.

Tell patient to Rubbing and

avoid rubbing and scratching can
scratching. cause further
Provide gloves or injury and delay
clip the nails if healing.
necessary.
 Instruct patient, Accurate
significant others, information
and family in increases the
proper care of the patients ability to
wound manage therapy
including hand independently
washing, wound and reduce risk
cleansing, for infection.
dressing changes,
and application of
topical
medications).

Educate patient This is to prevent

the need to notify further
physician or complications.
nurse.