Nursing Care Plan

Actual Case No. 1

Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Impaired Skin Short term Independent: Short term
Data: Integrity: skin goal: goal:
laceration and After 15 minutes Assessed skin. Establishes After 15 minutes
None abrasions of nursing Noted color, comparative of nursing
related to intervention, baseline providing intervention,
turgor,
Objective Vehicular opportunity for tim
Patient and sensation. Patient
Data: accident ely intervention
demonstrates Described and understand the
(+) 2 cm
laceration understanding of measured wounds plan of wound
wound plan to wound and observed healing
lateral healing changes Maintaining clean,
aspect, right dry skin provides a - Goal met
upper lid, Demonstrated Long term
barrier to infection
soft tissue Long term goal:
good skin . Patting skin dry
swelling with goal: At the end of the
hygiene, e.g., instead of rubbing
abrasion, After 3 days of 3-day
wash thoroughly reduces risk of
right nursing nursing interventi
zygomatic and pat dry dermal trauma to
intervention, the on, the client was
and right carefully. fragile skin
client will be able able to display
lateral eye,
to display improvement in
abrasions Skin friction
with soft improvement wound healing as
caused
tissue left in wound healing evidenced by:
by stif or rough
and right as evidenced by:
clothes leads to Minimized
frontal area,
Intact skin or Instructed family irritation of fragile presence of
abrasions,
left temporal minimized to maintain clean, skin and increases wounds.
area, tip of presence of dry risk for infection
nose at right wound. clothes, preferably Several wounds
cheek, right Absence of pain cotton fabric have dried up
paralatrial and itchiness
area, left - Goal met
nasal bridge.
On the
abdomen,
there is a Dependent:
(+) Administer the
abrasions on following
left hip and medications as to prevent tetanus
left mid flank per doctors
area. On the order
extremities,
there are (+) Anti-bacterial
multiple tetanus toxoid and
abrasions tetanus Ig
distal third
bilateral Anti-inflammatory
forearms, Cefuroxime,
ampicillin, To prevent excess
dorcum on
both hands, sulbactam, silver acid in the
dorsomedial sulfadiazine stomach
aspect right
foot, middle Etoricoxib Pain reliever
third right
anterior Omeprazole
legs, middle A high-protein,
third right high-calorie diet
forearm, left Paracetamol may be needed to
lateral knee, promote healing.
right knee, Collaborative:
right lateral Consult to
malleolus dietician for foods
 and right high in protein,
dorsal ankle. minerals and
vitamins

Actual Case No. 2

Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Acute pain Short term goal: Independent: Short term
Data: related to After 1-2 hours of goal:
tissue nursing After 1-2 hours of
Aray trauma/Body intervention, the Performed Pain is subjective nursing
masakit! trauma client Pain scale of comprehensive experience and intervention, the
verbalized by the client from 10 assessment each must be describe client Pain scale
the patient to 7 will decreased time pain occur by the client in of the client from
while cleaning to 10 to 5 order to plan 10 to 7
the wound efective decreased to 10
Long term goal: treatment. to 5
After 3 days of Position the
Objective nursing patient to him To provide - Goal met
Data: intervention, comport and Long term
comfortable
the client will relaxation goal:
Pain scale 7-10 be able to position After 3 days of
Facial grimace display nursing
(+) 2 cm improvement intervention, the
laceration wound in wound heali client will be able
Provide rest
lateral aspect, ng and report Pain may result to display
right upper lid, relive from periods to improvement
in fatigue, which
soft tissue pain and feels promote relief, in wound healing
may result in
swelling with comfortable sleep, and , report no pain
exaggerated
abrasion, right relaxation. at all.
zygomatic and pain. A peaceful
right lateral eye, and quiet - Goal met
abrasions with environment
soft tissue left may facilitate
and right frontal
rest
area, abrasions,
left temporal
area, tip of nose
at right cheek,
right paralatrial
area, left nasal
bridge. On the
abdomen, there
is a (+) Dependent:
abrasions on left Administer the
hip and left mid following
flank area. On medications
the extremities, as per doctors
there are (+) order Pain reliever
multiple
abrasions distal Paracetamol
third bilateral
forearms,
dorcum on both
hands,
dorsomedial
aspect right foot,
middle third
right anterior
legs, middle
third right
forearm, left
lateral knee,
right knee, right
lateral malleolus
and right dorsal
ankle

Potential Case No. 1

Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Risk in Short term Independent: Short term
Data: infection goal: goal:
After 8hours of Monitor vital Temperature After 15 minutes
None nursing signs. elevation and of nursing
intervention the tachycardia may intervention,
Objective Data:
client will be able reflect Patient
Laceration
to identify developing understand the
Abrasion on
behaviors and sepsis plan of wound
the Face and
both side of practices to healing
upper and prevent and Emphasize the It serves as a
lower reduce the risk importance first line of - Goal met
extrimities defense against Long term
for infection. of hand washing
infection. goal:
 Increased technique After 3 days of
WBC 16.1 Prevents entry of giving nursing
mg/L Long term Maintain aseptic bacteria, interventions,
goal: technique with any reducing risk of the client was
After 3 days of procedures. nosocomial free from sign of
giving nursing Provide routine infections. infection
interventions, site care/wound
the client will care, as Goal met
achieve timely appropriate
wound healing, Early detection of
free of signs of Inspect dressings developing
infection and wound; note infection
characteristics of provides
drainage. opportunity for
timely
intervention and
prevention of
more serious
complications

Dependent:
Administer the
following
medications as
per doctors
order

tetanus toxoid and to prevent

tetanus Ig
 tetanus

Cefuroxime,
ampicillin,
sulbactam, silver Anti-bacterial
sulfadiazine

Etoricoxib
Anti-
Omeprazole inflammatory

To prevent
Paracetamol excess acid in
the stomach
Collaborative:
Monitor white Pain reliever
blood cell (WBC)
count and notify
the physician An increasing
about the lab WBC count
result indicates the
bodys eforts to
combat
pathogens.