Cellulitis is a common, potentially serious bacterial skin infection. Cellulitis appears as a swollen, red area of skin that feels hot and tender, and...
.,this is a sample nursing care plan for patients with cerebral infarction (stroke). I have used this is our case study presentation (individual). It consist of 3 nursing care plan. Check it…Full description
Nursing Care Plan forFull description
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Nursing Care Plan ASSESSMENT
DIAGNOSIS
S : “Namamaga at namumula ang kanang paa ko.” As verbalized by the patinet.
Impaired skin integrity related to bacterial infection as manifested by the swelling of the right foot.
O: -swelling of the right foot -skin redness -skin lesions
PLANNIG
INTERVE NTION
EVALUATION
SHORT TERM GOAL : After 4 hours of rendering nursing intervention, patient will will be able to participate participate in preventive measures and treatment program.
INDEPEND ENT : >Identify underlying cause/condit ion involved. >Note changes in skin color, texture and turgor.
To assess extent of involvement/i njury.
After 4 hours of rendering nursing intervention, intervention, the client’s mother participated participated in preventive preventive measures and treatment programs for her child.
LONG TERM GOAL:
>Determine depth of injury/dama ge to integumenta ry system.
To assess extent of involvement/i njury.
>Inspect skin on a daily basis, describing lesions and changes observed.
To assist with correcting/min imizing condition and promote optimal healing.
After 1 week the client will be taught taught what a part of his body is at at most risk for skin break down
To assess causative/cont ributing factors.
>Keep the To assist area body’s natural natural clean/dry, process of prevent repair. infection, and stimulate circulation to surrounding areas. >Review importance of skin and
To promote wellness.
After week of teaching the client, he is seen doing a selfinspection of his lower extremities.
measures to maintain proper skin functioning. >Discuss importance of early detection of skin changes and/or complicatio ns. . DEPEDEN T: >Assist Nurse on duty in give prescribed IV meds as indicated.
ASSESSMENT
DIAGNOSIS
PLANNING
S : “Medyo ninerbyos na ako ng makausap ko ang doctor.” As verbalized by the patient.
Fear related to unfamiliarity with environmental experiences as evidenced by increased alertness.
After 8 hours of rendering nursing intervention, the client will lessen his fear.
-increased alertness -v/s taken as follows : P : 125 bpm R : 22 cpm
To promote wellness.
To relieve inflammation.
INTERVENTION
INDEPENDENT : >Note degree of incapacitation.
RATIONALE
To assess degree of fear and reality of threat perceived by the client.
>Measure vital signs/physiological responses to situation.
To assess degree of fear and reality of threat perceived by the client.
>Stay with the client or
Sense of
EVALUATION
After 8 hours of rendering nursing intervention, client’s fear has lessened.
make arrangements to have someone else be there.
abandonment can exacerbate fear.
>Identify client’s partner the responsibility for the solutions.
Enhances sense of control
>Instruct patient in use of relaxation/visualization and guided imagery skills.
Provides a helpful and healthy outlet for energy generated by fearful feelings and promotes relaxation.
ASSESSMENT
DIAGNOSIS
PLANNIG
S : “Namamaga at namumula ang kanang paa ko.” As verbalized by the patinet.
Impaired skin integrity related to bacterial infection as manifested by the swelling of the right foot.
SHORT TERM GOAL : After 4 hours of rendering nursing intervention, patient will be able to participate in preventive measures and treatment program.
O: -swelling of the right foot -skin redness -skin lesions
LONG TERM GOAL: After 1 week the client will be taught what a part of his body is at most risk for skin break down
INTERVENTION
EVALUATION
INDEPENDENT : After 4 hours of >Identify underlying rendering nursing cause/condition intervention, the involved. client’s mother R : To assess participated in causative/contributing preventive factors. measures and >Note changes in skin treatment programs color, texture and turgor. for her child. R : To assess extent of involvement/injury. >Determine depth of injury/damage to integumentary system. R : To assess extent of involvement/injury. After week of >Inspect skin on a daily teaching the client, basis, describing lesions he is seen doing a and changes observed. self-inspection of R : To assist with his lower correcting/minimizing extremities. condition and promote optimal healing. >Keep the area clean/dry, prevent infection, and stimulate circulation to surrounding areas. R : To assist body’s natural process of repair. >Review importance of skin and measures to maintain proper skin functioning. R : To promote wellness. >Discuss importance of early detection of skin changes and/or complications. R : To promote wellness. >Assist client’s mother in understanding and following medical regimen and developing program of preventive care and daily maintenance. R : Enhances commitment to plan,
optimizing outcomes. DEPEDENT : >Assist Nurse on duty in give prescribed IV meds as indicated. R : To relieve inflammation.
Discharge Planning
Get plenty of rest. This gives your body a chance to fight the infection.
Raise the area of the body involved as high as possible. This will ease the pain, help drainage and reduce swelling.
Please check the label for how much to take and how often. The pain eases once the infection starts getting better.
Be sure to take the full course of antibiotics.
You may be advised to make a follow-up appointment with your doctor to make sure the cellulitis is improving. Don’t forget to do this.
