ST.

ANTHONY’S COLLEGE
Nursing Department

NURSING CARE PLAN

Name of Patient: LCA Attending Physician: Dr. HME
Age: 90 yrs.old Ward/Bed Number: ICU-5 Impression/ Diagnosis: Community Acquired
Pneumonia- High Risk with Hypoxemia, Hypertension

Clustered Nursing Rationale Outcome Criteria Nursing Interventions Rationale Evaluation

Cues: Diagnosis

Subjective: Risk for Immobility, Within 8 hours of Independent:

impaired which leads to nursing 1. Reassess patient’s 1. To know the extent of
tissue pressure, intervention: skin condition the damage.
integrity shear, and 1. Patient’s skin
related to friction, is the will remain 2. Change the 2. Position changes
immobility factor most intact as patient’s position relieve pressure,
Objective: likely to put an evidenced by: frequently. restore blood flow,
(+)redness individual at  No redness and promote skin
Weak risk for altered over bony integrity
immobile skin integrity. prominence 3. Clean, dry and
VS Older patient’s and moisturize skin, 3. To reduce friction
BP: 160/100 skin is capillary especially over
Temp: 37.5° normally refill less bony prominences
PR: 92 bpm elastic and than as indicated by
RR: 19 cpm has less 6seconds incontinence or
02 sat: 98% moisture, over areas sweating. 4. Blisters are sterile
making for of redness natural
higher risk of 2. Patient’s family 4. Leave blisters intact
skin will verbalize by wrapping in 5. Skin friction caused
impairment the importance gauze or applying a by stiff or rough
of preventive hydrocolloid clothes leads to
measures. (Duoderm) irritation
5. Emphasize to the
family the
importance of
adequate nutrition
and oral fluid intake
 Immobility

Pressure
applied to soft
tissue

Complete or
partially
obstructed
blood flow to
the tissue

Shear or
friction

Pressure
ulcers
Student’s Name: KRISTINE L. YOUNG BSN 4
Clinical Instructor: DEANNAH LOU F. TAMPUS, RN