NURSING CARE PLAN

Assessment Diagnosis Planning Implementation Rationale Evaluation

Independent nursing action:

Subjective Data: Impaired skin Short Term  assess blood supply  to evaluate potential for After rendering all the
integrity related to Goal: and sensation of the impairment of circulation nursing intervention the
inflammatory After 8 hours of affected leg to lower extremity patienl:
condition of skin nursing  determine nutritional  lack of nutrition and
and severe intervention the status and potential for protein in diet will  understands the
scratching as patient will delayed healing by caused delayed in importance of
Objective Data: manifested by understand the malnutrition healing proper
disrupted skin importance of  note skin color, texture  for future comparison handling/caring
 Disruption of surface and tissue preventive and turgor of his wound
skin surface and with moist scales, measures and  determine degree of and treatment.
tissue layers erythema and proper treatment injury to integumentary
 Moist scales fissures for his lesion system
 erythema Long Term Goal:  note odor emitted from  for future comparison
After 2 weeks of skin lesion
nursing  inspect skin on daily  to observe changes in
intervention the basis lesion
patient  keep area clean and dry  to assist body’s natural
wound/lesion will process of repair
timely heal  apply appropriate  for wound dressing
dressing
 encourage ambulation  promotes circulation
 provide optimum  to provide a positive
nutrition, including nitrogen balance to aid
vitamin c, and increase in skin/tissue healing
protein intake

 emphasize to patient  to reduce the

 the importance of microorganism inhibiting
proper cleaning of at the wound
wound with antiseptic
soap
Dependent nursing action:
 administer antibiotic
(cephalexin) as
prescribed

Reference: Nurse’s Pocket

guide 11th edition
Marilynn E. Doenges
Pages: 619-623