NURSING CARE PLAN

Name of Patient: L. M. D. Ward/Bed Number: CW2 Impression/Diagnosis: Cerebrovascular Accident (CVA)

Age/Sex: 58/M Attending Physician: Dr. V.

CUES NURSING OUTCOME

RATIONALE NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS CRITERIA
OBJECTIVE: Impaired Impaired physical INDEPENDENT: Goal Fully Met.
physical mobility is a After 8 hours of
>Right sided mobility limitation in nursing 1.) Establish rapport. 1.) To promote cooperation. After 8 hours of
paralysis related to independent, intervention the nursing
> Inability to decrease purposeful physical patient will be able 2.) Assess the client’s condition. 2.) To establish comparative intervention the
speak strength and movement of the to display decrease baseline data for nursing care. patient was able
> with endurance body or of one or signs of ineffective to display
Tracheostomy more extremities. tissue perfusion as 3.) Encourage participation in 3.) Provides opportunity for decrease signs of
>with NGT evidence by diversional or recreational release of energy, refocuses ineffective tissue
>Pale gradual activities (e.g. radio, TV, attention, enhances client’s sense perfusion as
conjuctiva Effects of immobility improvement of newspapers, personal of self-control and self-worth, and evidence by
> capillary refill are particularly vital signs. possessions, pictures, clock, aids in reducing social isolation. gradual
of 4 seconds dangerous in older calendar, and visits from family improvement of
>Weakness adults. Muscle and friends). vital signs with
>Poor muscle weakness, atrophy, vital signs as
tone and decreased 4.) Reposition periodically and 4.) Prevents or reduces incidence follows:
endurance occur encourage coughing and deep- of skin and respiratory
>V/S taken as quickly, and breathing exercises. complications—decubitus ulcer, BP: 120/80
follows: biochemical and atelectasis, or pneumonia. mmHg
physiologic effects P: 68 bpm
BP: 140/80 such as nitrogen loss 5.) Encourage increased fluid 5.) Keeps the body well hydrated, R: 20 cpm
mmHg and hypercalciuria intake of 2000 to 3000 mL/day decreasing risk of urinary T: 36.7 °C
P: 57 bpm are important to within cardiac tolerance, infection and stone formation, and O2 Sat: 99 %
R: 28 cpm consider (Porth, helps to prevent constipation.
T: 37.3 °C 2010).
O2 Sat: 95 %
CUES NURSING OUTCOME
RATIONALE NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS CRITERIA

Sources: 6.) Change positions at least 6.) Reduces risk of tissue injury.
every 2 hrs. (supine, side lying) Affected side has poorer
> Nursing diagnosis and possibly more often if placed circulation and reduced
handbook (2006) 7th on affected side. sensation and is more
Ed. by Ackley, B.J., & predisposed to skin breakdown.
Ladwig, G.B.
7.) Observe affected side for 7.) Edematous tissue is more
color, edema, or other signs of easily traumatized and heals
>Brunner & Suddarth’s compromised circulation. more slowly.
textbook of Medical –
Surgical Nursing
(2010) 12nd Ed. by
Smeltzer, Barre, Hinkle
& Cheever.
 NURSING CARE PLAN
Name of Patient: R. C. G. Ward/Bed Number: CHA2 Attending Physician: Dr. P.
Age/Sex: 65/F Impression/Diagnosis: T/C Sepsis 2⁰ to catheter induced UTI & Decubitus ulcer

CUES NURSING OUTCOME

RATIONALE NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS CRITERIA
SUBJECTIVE: Skin protects the GENERAL: INDEPENDENT: GOAL MET:
“Nagka pila run Impaired body against 1.) Assess between folds of skin, 1.) Pressure ulcers under medical
si nanay hay skin integrity infections and After 3 days of remove anti embolic stockings devices are commonly overlooked. The patient was
nagabatang related to diseases brought nursing or devices & use a mirror to see able to:
lang run tana pressure about by the invasion interventions, the the heels. Also assess under
kag indi run gid ulcer of microbes in the client will: oxygen tubing especially on the > Experience
kahulag.”, as secondary to body. Pressure on ears & the cheek. healing of ulcer/
verbalized by prolonged soft tissues between >Experience regain skin
the grandson of immobility bony prominences healing of ulcer/ 2.) Note objective data of 2.) Reassessment of ulcer is integrity(reduce
the patient. and compresses regain skin pressure ulcer (stage, length, completed each time dressing are size of ulcer)
unrelieved capillaries & occludes integrity(reduce width, depth, wound bed changed or sooner if ulcer shows
pressure. blood flow. When the size of ulcer) appearance, drainage & manifestations of deterioration. >Reduce risk for
OBJECTIVE: pressure was not condition of periulcer tissue) infection
> Presence of relieved there will be >Reduce risk for
stage 2 a micro thrombi infection > Have reduced
pressure ulcer formation that 3.) Increase the frequency of 3.) To disperse pressure over time risk of further
on the sacral occludes in the SPECIFIC: turning (turning q2). Position or decreasing the tissue load. impairment of
area and left capillaries & blood the client to stay off the ulcer. skin integrity.
lower leg. flow that could lead After 6-8 hrs. of
> Dry &shallow to formation of nursing 4.) Follow body substance 4.) To reduce risk of infection >Patients
wound blisters then rupture interventions of isolation precautions; use clean caregivers
> Reddish-pink of blister and open nursing gloves & clean dressing for demonstrate
open/rupture wound and interventions, the wound care. Practicing proper understanding
blister. eventually will result client will: hand washing before & after &skill in care of
to pressure ulcer. wound care. wound.
 CUES NURSING OUTCOME
RATIONALE NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS CRITERIA
>V/S taken as
follows: Sources: >Have reduced risk 5.) Prevent the ulcer from being 5.) To prevent contamination/
BP: 130/80 of further exposed to urine & feces. Use spread of infection.
mmHg > Nursing diagnosis impairment of skin indwelling catheters, bowel
P: 91 bpm handbook (2006) 7th integrity. containment systems, & topical
R: 23 bpm Ed. by Ackley, B.J., & creams or dressings.
T: 36.5 °C Ladwig, G.B. >Patients
O2 Sat: 99 % caregivers will 6.) Maintain head of bed at the 6.) To prevent further
demonstrate lowest elevation, if client must have occurrence of pressure ulcer.
> Medical-surgical understanding & the head elevated to prevent
aspiration, reposition to30 degree
nursing: Clinical skill in care of
lateral position. Use seat cushions
management for wound &assess sacral ulcers daily.
positive outcomes
(2009) 8th Ed. by Black, 7.) Remove devitalized tissue 7.) To promote faster healing &
J.M. & Hawks, J.H. from the wound bed, except in the reduce infection
avascular tissue or on the heels.
Began by cleansing the ulcer bed
with normal saline, then use
appropriate technique for
debridement. Once the ulcer is free
of devitalized tissue, apply dressing
the keep the wound bed moist & the
surrounding skin dry. Do not use
occlusive dressings on ulcer.

DEPENDENT:

8.) Administer antibiotics such as 8.) Cefazolin binds to bacterial

Cefazolin (Stancef) as ordered. cell wall membrane, causing cell
death.