NURSING CARE PLAN

IMPAIRED SKIN INTEGRITY

ASSESSSMENT NURSING DIAGNOSIS PLANNING INTERVENTION EVALUATION
SUBJECTIVE: >Inspect skin on daily
>‘’masakit parin po Impaired skin At the end of 8 hrs. basis and changes Goal met, after 8
yung ngipin ko pati integrity shift the patient observed. hr. Shift the
po left side ng will: >provide optimum patient:
mukha ko namaga’’ nutrition and increase
as verbalized by > maintain optimal protein intake- to > maintain optimal
the patient. nutrition/ physical provide a positive nutrition/
well-being. nitrogen balance to aid physical well-
OBJECTIVE: >participate in in healing and to being.
>swelling of left prevention measures maintain general good >participate in
face and treatment health. prevention
program. > discuss importance of measures and
> verbalized early detection of skin treatment program.
feelings of changes and/or > verbalized
increased self- complications. feelings of
esteem and ability > encourage patient to increased self-
to manage situation. verbalize feelings and esteem and ability
discuss how /if to manage
condition affects self- situation.
concept/ self-esteem.
>ensure safety at all
times
>emphasize importance of
adequate nutritional/
fluid intake - to
maintain general good
health and skin turgor.
ALTERATION IN COMFORT DUE TO PAIN
ASSESSMENT NURSING PLANNING INTERVENTION EVALUATION
DIAGNOSIS
SUBJECTIVE: DEPENDENT:
> ‘’masakit Alteration in At the end of > administer analgesic as Goal met, after 8
parin po yung comfort due to the shifts the indicated to maximal dosage as hrs. shift the
ngipin ko pati pain patient will: needed - to maintain patient:
po left side >Report pain is ‘acceptable’ level of pain. > verbalized
ng mukha ko relieve/ relief and/ or
namaga’’ as controlled INDEPENDENT: control of pain/
verbalized by > demonstrate >work with the client to discomfort
the patient. use of prevent pain. Instruct client >demonstrate use
relaxation to report pain as soon as it of relaxation
OBJECTIVE: skills and begins- as timely intervention skills and
>swelling of diversional is more likely to be successful diversional
left face activities as in alleviating pain. activities as
> appears indicated for >encourage verbalization of indicated
irritable individual feelings about pain
situation. >ensure safety at all times.
> provide quiet environment.
>provide rest and comfort.
>emphasized the importance of
hydration.
>instruct /encourage use of
relaxation exercises and
diversional activities, such as
focused breathing, commercial
or individualized tapes (e.g.
Music)
IMPAIRED ORAL MUCOUS MEMBRANE
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION EVALUATION
SUBJECTIVE: DEPENDENT:
‘’maayos parin Impaired oral At the end of the >administer analgesic Goal met, after
naman po ang mucous membrane sift the patient as indicated- to the 8hr. Shift
pagkain ko, pero will: reduced oral the patient:
pakonti konti discomfort/ pain
nalang po gawa ng > identify >administer > identify
masakit ang ngipin specific antibiotics as specific
ko’’ as verbalized interventions to ordered, when interventions to
by the patient. promote healthy infection is present promote healthy
oral mucosa oral mucosa
OBJECTIVE: > demonstrate INDEPENDENT: > demonstrate
>swelling of left techniques to > determine nutrition techniques to
face restore / maintain / fluid intake and restore /
integrity of oral report changes. maintain
mucosa > routinely inspect integrity of oral
> report / oral cavity for mucosa
demonstrate a sores, lesions, > report /
decrease in and/or bleeding. demonstrate a
symptoms/ >encourage adequate decrease in
complaints fluids - to prevent symptoms/
dehydration complaints
>provide frequent
oral care
>provide adequate
nutritional intake
DISTURBED BODY IMAGE
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION EVALUATION
SUBJACTIVE:
> ‘’mejo nahihiya Disturbed body At the end of the > evaluate level Goal met, after 8
po ako minsan gawa image 8 hr. Shift the of client’s hr. Shift the
ng namamaga po patient will: knowledge of and patient:
yung mukha ko’’ as anxiety related to
verbalized by the >verbalize situation. >verbalized
patient acceptance of self Observed emotional acceptance of self
in the situation changes. in the situation
OBJECTIVE: >verbalize relief >verbalized relief
>swelling of left of anxiety and >encourage patient of anxiety and
face adaptation to to verbalize adaptation to
altered body image feelings and altered body image
> verbalize discuss how /if > verbalized
understanding of condition affects understanding of
body changes self-concept/ body changes
self-esteem.

> assist in
correcting
underlying
problems- to
promote optimal
healing
 DRUG STUDY

Drug Name Classification Mechanism of action Contraindications Adverse Nx.

effects Responsibilities
Generic Name: Clindamycin is Clindamycin acts by Clindamycin is Diarrhea, • Advise patient
Clindamycin a medication inhibiting contraindicated Decrease to take capsule
used for the bacterial protein in individuals in the form with a full
Brand Name: treatment of synthesis at the with a history amount of glass of water
Acanya and numerous level of the 50S of urine, to prevent
Benzaclin infections, ribosome. As a hypersensitivity Nausea, esophageal
including but result, it exerts a to preparations Chills irritations.
Actual not limited to prolonged post containing and cough • Warn patient
dosage:300mg septicemia, antibiotic effect. clindamycin or that IM
Route: IV intra- It may decrease lincomycin. injection may be
abdominal toxin production painful.
infections, and increase • Tell patient
lower microbial to report
respiratory opsonization and discomfort at IV
infections, phagocytosis even insertion site.
gynecological at subinhibitory • Instruct
infections, concentrations. patient to
bone and joint report all
infections, adverse
and skin and reactions
skin structure (especially
infections. diarrhea and
hypersensitivity
reactions).
 Drug Name Classification Mechanism of Contraindications Adverse Nx. Responsibility
action effects
Generic Paracetamol is a Paracetamol has a Contraindicated Sweating, • Advise parents
Name: medicine used to central analgesic in known nausea, dark that drug is only
paracetamol treat mild to effect that is hypersensitivity urine, for short term
moderate pain. mediated through to paracetamol, decrease use.
Brand Name: Paracetamol can activation of in hepatic and urination • Tell patient to
Dymadon, also be used to descending renal failure. consult prescriber
Lemsip, treat fever (high serotonergic for fever lasting
Panadol, temperature). pathways. Debate longer than 3 days
Panamax, It's dangerous to exists about its or recurrent
Tylenol take more than primary site of fever.
the recommended action, which may - Tell patient who
Actual dose of be inhibition of is breastfeeding
dosage: paracetamol. prostaglandin appears in human
300mg Paracetamol (PG) synthesis or milk in low
Route: Po overdose can through an active levels. Drug may
damage your liver metabolite be used safely if
and cause death. influencing therapy is short-
cannabinoid term and doesn't
receptors. exceed recommended
doses.
 Drug Name Classification Mechanism of Contraindications Adverse Nx.
action effects Responsibility
Generic Name: Mefenamic acid Mefenamic acid Mefenamic acid is swelling of Monitor for
mefenamic is in a class binds the contraindicated the face, symptoms and/or
of medications prostaglandin in patients with fingers, feet, signs
Brand Name: called NSAIDs. synthetase active ulceration or lower legs, suggesting
ponstan It works by receptors COX-1 or chronic severe stomach liver
stopping the and COX-2, inflammation of pain, black, dysfunction.
Actual dosage: body's inhibiting the either the upper tarry stools, Monitor
500mg production of a action of or lower or vomiting abnormal liver
substance that prostaglandin gastrointestinal function test
Route: PO causes pain, synthetase. As tract and should results.
fever, and these receptors be avoided in Discontinue if
inflammation. have a role as patients with signs or
a major pre-existing symptoms of
mediator of renal disease. liver disease
inflammation Treatment of or systemic
and/or a role peri-operative manifestations
for proteinoid pain in the
signaling in setting of
activity- coronary artery
dependent bypass graft
plasticity, the (CABG) surgery.
symptoms of
pain are
temporarily
reduced.