NURSING CARE PLAN

Cues Nursing Diagnosis Rationale to Nursing Goals and Objectives Nursing Rationale to Nursing Evaluation
Diagnosis Interventions Interventions
Subjective: Impaired tissue What constitutes our Short term range Independent: Short term:
“I have an open integrity related to body’s protection After 5 hours of  Monitor site of  Systematic After 5 hours nursing
wound, as verbalized inflammatory against external nursing intervention, impaired tissue inspection can interventions the patient
by the patient process damaging threats? Yes, it’s the patient will: integrity at identify shall:
skin and underlying the integumentary  Show least once impending  Patient showed
Objective: tissue, secondary to system, specifically, improvement daily for color problems early. improvement of
Temperature: 37 C cellulitis, manifested
o
our skin, cornea, of s/sx of changes, signs and symptoms
(98 oF) by pain, redness, subcutaneous tissues, infection. redness, of infection. This
Pulse rate: 88 swelling, and and mucous  Client will swelling, included a decrease
beats/min. warmth of site. membranes are our maintain warmth, pain, in warmth and
Respirations 24 first line of defense adequate or other signs redness and a stable
cycles/min. against threats from nutrition. of infection. oral temperature
Blood Pressure: the external  Client will within the normal
136/90 mmHg environment. report a  Monitor status  Individualize range.
tolerable level of skin around plan is  Patient consumed
Height: 177.8 cm In a normal setting, of pain. wound. necessary >75% of meals
(5’10”) these defenses are  Patient shall be Monitor according to throughout shift.
Weight: 72. 7 kg (160 adequate to defend free from patient’s skin patient’s skin Patient understood
lb.) the body from any infection and care practices, condition, the need of adequate
threats, however, all risks are noting type of needs, and nutrition not only to
 Pain there are factors that minimized. soap or other preferences. promote healing but
 Wound may cause  Patient will cleansing also in regards to his
laceration 9cm impairment or a break gain agent used, immunosuppression.
(3.5 inch) in this line of defense knowledge in temperature of  Patient exhibit no
causing impairment infection water, and signs and symptoms
of tissue integrity. control as frequency of of infection.
evidenced by skin cleansing.  Patient was able to
discussing the gain knowledge in
The most common
wound care. infection control.
cause includes
physical trauma (e.g.,
car accident, sports Long term range: Long Term:
injury, cuts, blunt Following a 3 days of  Keep a sterile  This technique At the end of the 3 days of
trauma, etc.,). Other nursing intervention, dressing reduces the risk nursing intervention, the
causes can be related the client will be able techniques of infection in client was able to display
to thermal factors to display during wound impaired tissue improvement in wound
(e.g., burns, improvement in care. integrity. healing as evidenced by:
frostbites), or wound healing as  Minimized presence
chemical injury (e.g., evidenced by:  If patient is in  This is to of wounds
adverse reactions to  Intact skin or content, prevent  Several wounds
drugs), infection, minimized implement an exposure to have dried up.
nutritional presence of incontinence chemicals in  Minimized
imbalances, fluid wound. management urine and stool erythema.
imbalances, and  Wound is less plan. that can strip or  Minimized purulent
altered circulation than 9cm erode the skin. discharge
(e.g., pressure ulcers). (3.5inch)  Wounds are still at
laceration  V/S monitor  To follow up least 9cm (3.5inch)
A break in tissue  Absence of and record important laceration (continue
integrity is normally redness or changes. cleaning the wound
repaired by the body erythema. with disinfectant)
very well, though  Absence of  Presence of
there are purulent itchiness. 9 continue
circumstances that it discharge instructing client to
doesn’t repair it at all  Absence of avoid scratching the
itchiness Dependent:
and replaces the wound)
damaged tissue with  Administer  Wound
connective tissue. prescribed pain infections may
When tissue integrity medications, be damaged
is left untreated, it antibiotics and well and more
could cause local or other efficiently with
systemic infection medications as topical gents,
and ultimately lead to ordered. although
necrosis. intravenous
Source: Wayne BSN, antibiotics may
R.N. (2008), impaired be indicated.
tissue integrity,
nurseslabs.com and
Kozier, B. et al. Collaborative:
Fundamentals of  Refer to a
Nursing (8th Ed.). physician or  This is to
Pearson Education nurse when prevent further
South Asia Pte Ltd. indicated. impaired tissue
integrity
complications.