DAVAO DOCTORS COLLEGE

Gen. Malvar St., Davao City

Nursing Program

NURSING CARE PLAN

Name of Patient: Marcos Rods Date of Admission:Sept 12, 2022 Room:143

Age:55 Sex: Male Civil Status: Married Chief Complaint: Edema
Religion: Attending Physician: Dr. Beng Gow
PROBLEM SCIENTIFIC BASIS GOAL/OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
After 8 hours of nursing
interventions
S- Risk for impaired skin After 6-8 hours of nursing Assess between folds of skin, Pressure ulcers under medical
integrity interventions, the client will remove anembolic stockings or devices are commonly overlooked. -Responses
devices & use a mirror to see the interventions/teaching plans a
heels. Also assess under oxygen actions performed.
O- tubing especially on the ears &
Vital Signs Have reduced risk of further the cheek, beneath splints and
RR- 39 skin integrity' refers to the impairment of skin integrity -Attainment/progress towa
under medical devices desired outcome(s)
PR-108 skin being a sound and
BPM-120/100 complete structure in Patient’s caregivers will
SpO2-89% unimpaired condition. demonstrate understanding & Heel covers do not relieve pressure, -Modifications of plan of care
Conversely, impaired skin skill in care of wound but they can reduce friction
integrity is defined as an
"altered epidermis and/or Elevate heels of the bed by
using pillows or heel elevation To prevent further occurrence of
dermis destruction of skin pressure ulcer.
layers (dermis), and Botts
disruption of skin surface
(epidermis)"
Maintain head of bed at the
lowest elevation, if client must
have the head elevated to
To reduce risk of infection
prevent aspiration repositiononto
30 degree lateral position. Use
.
seat cushions & assess sacral
ulcers daily.
Follow body substance isolation
precautions use clean gloves
&clean dressing for wound care.
Practicing proper handwashing
before & after wound care.

APALISOK, GERARD JAN

Name of Student