POTENTIAL NURSING CARE PLAN

ASSESSMENT EXPLANATION OF THE PLANNING IMPLEMENTATION RATIONALE EVALUATION

PROBLEM
Subjective: Wounds involving STO:  Assess signs  Fever may STO:
“May sugat sya sa injury to soft tissue can After 8 hours of nursing and symptoms indicate Goal met. Patient’s
bandang likod at sa vary from minor tears intervention, patient of infection infection wounds were dry and
may pwet. Minsan to severe crushing will achieve timely especially the free from any drainage
nalalagyan ng ihi or injuries. The decision to wound healing, be free temperature. or secretions. Watcher
dumi kung di suture a wound of purulent drainage or was able to verbalize
napapalitan agad yung depends on the nature erythema and be  Emphasize the  It serves as a the importance of log
diaper.” of the wound the time afebrile. Watcher will importance of first line of rolling and
since the injury was be able to verbalize hand hygiene defense against demonstrated on how
Objective: sustained and the understanding of infection. to do so.
 Weak in degree of individual causative or  Maintain aseptic  Regular wound
appearance contamination. risk factors and technique when dressing LTO:
 Open Bed Sores demonstrate cleaning or promotes fast Goal met, patient did
present on the techniques or lifestyle dressing wound healing and not manifest any signs
sacral area. changes to reduce the drying of and symptoms of
 T = 36.7 risk. wounds. infection as manifested
by absence of fever.
Nursing Diagnosis: LTO:  Keep area  Wet area can be
Risk for Infection After 3 days of nursing around wound a lodge area for
intervention, Patient clean and dry bacteria.
will not manifest any
signs and symptoms of  Emphasize the  Premature
infection. necessity of discontinuation
taking of treatment
antibiotics as when patient
ordered. begins to feel
well may result
in return of
infection.
 Assess areas in  Use of
groin, perineum antibiotics and
and under arms trapping of
and breasts. moisture in
skinfold areas
increases risk of
Candida
infections.