Nursing care of skin integrity
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Nursing care of skin integrity.
NURSING CARE PLAN FOR JASEL (FEBRUARY 26-28, 2007)
Subjective:“May mga sugat ako.”
as vera!"#e$ % &'ea&"e&*
Objective:
+"sr&" . s/"sr.ae a& &'e 1!er e3&re4"&%*
5$ "s 44 "$"a4e&er*
La!"#e$ er%&'e4a
Pr!e& $"s'are
() rr"&s &'es"&e . &'e $*
() a"
Impaired skinintegrityrelated toinflammatoryresponsesecondary toinfection.
F!!" a 9-$a%rs" "&erve&",&'e !"e& "!! e a!e& $"s!a% "4rve4e&" $ 'ea!" asev"$ee$ %:
I&a& s/" r 4""4"#e$resee . $*
5$ "s !ess &'a44 " $"a4e&er*
Asee . re$essr er%&'e4a*
Asee . r!e& $"s'are*
Asee . "&'"ess*
Assesse$ s/"*N&e$ !r, &rr,a$ sesa&"*+esr"e$ a$4easre$ $sa$ serve$'aes*
+e4s&ra&e$ $s/" '%"ee, e**,as' &'r'!%a$ a& $r%are.!!%*
Is&r&e$ .a4"!% &4a"&a" !ea, $r%!&'es, re.era!%&& .ar" (a% ;-s'"r&)*
Es&a!"s'es4ara&"vease!"e rv"$"r&"&% .r &"4e!% "&erve&"*
<a"&a"" !ea,$r% s/" rv"$es aarr"er & ".e&"*Pa&&" s/" $r%"s&ea$ . r"re$es r"s/ . $er4a! &ra4a &.ra"!e s/"*
S/" .r"&" ase$% s&".. r r'!&'es !ea$s &"rr"&a&" . .ra"!es/" a$ "reasesr"s/ .r ".e&"* A& &'e e$ . &'e 9-$a%rs" "&erve&",&'e !"e& as a!e &$"s!a% "4rve4e& "$ 'ea!" asev"$ee$ %:
<""4"#e$ resee. $s*
Severa! $s'ave $r"e$ *
<""4"#e$er%&'e4a*
<""4"#e$ r!e&$"s'are*
5$s are s&"!! a&!eas& 44 "$"a4e&er* (C&"e!ea" &'e $"&' $"s".e&a&)
Presee . "&'"ess* (C&"e=
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
E4'as"#e$"4r&ae . a$e>a&e &r"&"a$ .!"$ "&a/e*
+e4s&ra&e$ &&'e .a4"!% 4e4ers ' & 4a/e aava $e&" &a!% & &'e $as a!&era&"ve$"s".e&a&*
Is&r&e$ .a4"!% &!" a$ ."!e a"!sre!ar!%*
Prv"$e$ a$a!"e$ $$ress"s are.!!%*
I4rve$ &r"&"a$ '%$ra&" "!!"4rve s/"$"&"*
Prv"$" &'e .a4"!%"&' a!&era&"ves!&" ass"s&s&'e4 " &"4a!'ea!" "&' !esse3es"veresres*
L a$ r'a"!s "rease r"s/. s/" $a4ae*
5$ $ress"sr&e& &'e $a$ &'esrr$"&"sses*"s&r&" !"e& &av"$ sra&'" &'e$)2
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
NURSING CARE PLAN FOR ;?E FA<ILY (<ARC? -7, 2007)
Subjective:“Makati po ang uloko.”
as vera!"#e$ %&'e a&"e&*
Objective:
Presee . s4a!!,'"&e .!e/s 'a"r s'a.& a& &'e a/ . &'e 'ea$ (es . !"e)*
Prr"&s &'esa!*
E3r"a&" &'esa!*
R', $r% 'a"r*
Impaired skinintegrity(scalp) relatedto parasiticinfestationsecondary todirecttransmissionof theorganism.
F!!" a 9-$a%rs" "&erve&",&'e !"e& "!! e a!e& $"s!a% &"4e!%'ea!" . sa!e3r"a&"s "&'&4!"a&"s asev"$ee$ %:
Asee . s4a!!,'"&e .!e/s 'a"r s'a.& (e !"e)*
Asee . rr"&s &'e sa!*
Asee . e3r"a&"s &'esa!*
Assesse$ ea'.a4"!% 4e4er .r 'ea$ !"e*
+e4s&ra&e$ &.a4"!% ' & 4a/ea ar4 v"ear s!&" (= v"ear 4"3e$ "&'= a&er)*
C4e$ &'ea&"e&@s 'a"r &'r'!% "&' a."e-&&'e$ 4$"e$ " v"ear*
Is&r&e$ &'e.a4"!% & s&ar& &'e&rea&4e&"44e$"a&e!% e
;'e ra"s4 "seas"!% &ras4"&&e$% $"re& '%s"a!&a&*
"ear 'e!s &re4ve a%re4a"" "&s r "&s'e!!s .r4 &'e 'a"r s'a.&*
F"e-&&'e$ 4s'e! re4ve "&s'e!!s .r4 &'e 'a"r s'a.& a$ re$esr"s/s .r re".es&a&"*
;'"s $"&"srea$s ra"$!%* A& &'e e$ . &'e 9-$a%rs" "&erve&",&'e !"e& as a!e &$"s!a% &"4e!% 'ea!". sa! e3r"a&"s"&'& 4!"a&"sas ev"$ee$ %:
<""4"#e$e3r"a&"s &'esa!*
<""4"#e$ "&'"ess &'e sa!*
Presee . e!"e (C&"e4" 'a"r "&'."e-&&'e$ 4)*9
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
&'ere "s resee . es a& &'e 'a"r s'a.&*
5are$ '"!$re& & s'are 4s,rs'es a$ 'a&s"&' &'er e!e*
Is&r&e$ .a4"!% &as' a!! !&'",&e!s a$e$$"s " '&a&er a& !eas& Cr 'a $er &'es & $r%*
?ea$ !"e a a!se &ras4"&&e$"$"re&!% &'r'".es&e$ 4s,rs'es, "s, 'a&sa$ e$$"s*
5as'" a!!!&'"s " '&a&er reve&sre".es&a&"*
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