Nursing Care Plan

ASSESMENT | GOAL OF CARE | PLAN OF ACTIONS | RATIONALE | IMPLEMENTATION | DOCUMENTATION | Subjective:“Daghan man na siya samad ug hubag sa iyang lawas”(She has many wounds and bruises on her body) as verbalized by the mother.Objective:-Presence of lesions and abrasions on the patient’s body.-greenish violet discolorated patches-soaked dressingNursing Diagnosis:Risk for impaired skin integrity related to superficial factors. | At the end of 8 hours nursing interventions, the client will be able to: 1. Display improvement in wound healing. 2. Patient will verbalize the measures needed to promote good skin integrity by discharge. 3. Will not develop any further skin breakdown during her stay at the facility. | 1. Assessed skin. Noted color, turgor, and sensation. Described and measured wounds and observed changes. 2. Demonstrated good skin hygiene, e.g., wash thoroughly and pat dry carefully. 3. Educate the family on the importance of keeping the skin clean and dry. 4. Emphasized importance of adequate nutrition and fluid intake. 5. Reposition the patient at least once every two hours. 6. Monitor skin condition at least once a day for color or texture changes, dermatological conditions, or lesions. | 1. Establishes comparative baseline providing opportunity for timely intervention. 2. Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin. 3. Moisture softens the skin and causes a break in the skin integrity. 4. Improved nutrition and hydration will improve skin condition. 5. Positioning interventions reduce pressure and shearing force to the skin. 6. Systematic inspection can identify impending problems early. | | |

Generic Name:Tetanus Toxoid | | | | Brand Names: Adacel, Boostrix | INDICATION: Tetanus Toxoid is indicated for booster injection only for persons 7 yrs of age and older against tetanus. Primary immunization schedule