NURSING CARE PLAN FOR IMPAIRED SKIN INTEGRITY
IMPLEMENTATION
ASSESSMENT DIAGNOSIS PLANNING EVALUATION
INTERVENTION RATIONALE
Objective Data: Impaired Skin At the end of Independent: Goal Met.
erythema Integrity related nursing At the end of
warmth to inflammatory interventions, Establish To gain patient's trust nursing
swelling process the patient will rapport. and for her to be interventions,
damaging skin be able to cooperative in the client will be
and underlying participate in treatment and care. able to
tissue secondary preventive participate in
to cellulitis, as measures and preventive
evidenced by manifest Keep the Keeping the skin measures and
erythema, reduced the patient’s skin clean and dry helps treatment
warmth and redness and clean and dry. to prevent further program and
swelling of the swelling, and infection and maintain skin
affected area maintain promotes healing. integrity.
Apply warm Warm compresses
compresses to help to increase
the affected blood flow to the
area to affected area, which
decrease pain can reduce pain and
and inflammation.
inflammation.
Monitor the Monitoring vital signs
patient's vital can help to identify
signs, any signs of infection
including or worsening
temperature, cellulitis.
heart rate, and
blood
pressure.
Teach the Educating the patient
patient about about signs of
signs of infection can help
infection, such them to identify any
as worsening complications early
redness or and seek prompt
swelling, medical attention.
discoloration,
or drainage.
Encourage the These symptoms can
patient to indicate a severe
report any infection and require
fever, changes immediate medical
in breathing, attention.
or loss of
consciousness
immediately.
Provide pain Pain management
management can help to improve
as needed. the patient's comfort
and promote healing.
Dependent: Antibiotics are the
Administer primary treatment for
antibiotics as cellulitis. They help to
prescribed by eliminate the
the physician. bacterial infection
and prevent it from
spreading.
NURSING CARE PLAN FOR RISK FOR INFECTION
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION
INTERVENTION RATIONALE
Risk for Upon the Independent Goal met, Following
infection completion of the conclusion of
nursing and Assess the Comprehensive nursing and
collaborative patient’s skin on skin collaborative
interventions, it is his/her whole body. assessment is interventions, the
important to
expected that the identify the patient exhibited
patient will be extent of the absence of
devoid of systemic cellulitis, systemic infection
infection potential indicators,
manifestations, such complications, demonstrated
and to monitor
as fever, compliance with the
the progress of
tachycardia, and treatment. It recommended
confusion and show helps in early cellulitis treatment
adherence to the detection of plan, and displayed
prescribed any changes or sufficient
treatment regimen worsening of understanding of
for cellulitis the condition. cellulitis-related
information.
Educate the patient Proper
and significant hygiene,
other about proper including
regular
skin hygiene
cleaning with
through washing it soap and
with soap and water, helps
water. prevent
secondary
infections and
maintains
overall skin
health.
Education
empowers the
patient and
their caregivers
to take an
Maintain a clean active role in
and sterile managing their
environment. condition.
Infection
control is
essential to
prevent
secondary
infections, so
it's important to
maintain a
Dependent clean and
sterile
Administer environment in
antibiotics as the care of the
patient with
prescribed. Ensure
cellulitis.
that the patient
finishes the course
of antibiotic Cellulitis is
prescribed by the often caused
physician. by bacterial
infection, and
antibiotics are
necessary to
treat the
infection.
Completing the
full course of
antibiotics is
crucial to
ensure
complete
eradication of
the bacteria
Monitor for allergic and prevent
reactions or side recurrence or
effects to antibiotic
prescribed resistance.
antibiotics
Some
individuals may
have allergies
or adverse
reactions to
antibiotics, so
close
monitoring is
necessary to
ensure the
patient's safety.
NURSING CARE PLAN FOR DISTURBED BODY IMAGE
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION
INTERVENTION RATIONALE
The patient Disturbed Following the 1. Establish rapport Essential for Goal Met.
verbalized that body image completion of and assess client’s planning At the end of
“nakakahiya po related to nursing perception of his appropriate nursing
kasi baka Makita physical interventions, it body image interventions interventions, the
po ng iba yung changes due is expected that and for better client is able to
bukol sa mukha to illness as the patient will healthcare verbalize an
ko, baka mandiri po evidenced verbally express acceptance of his
sila” by reports of acknowledgment body image and
feeling self- and embrace a able to determine
conscious positive 2. Provide education Helps the client the signs of his
about perception of his about body image to understand illness
appearance body image. and its development. the factors
This can include contributing to
recommending his negative
books, articles, or self-perception.
support groups that
focus on body
positivity and self-
acceptance.
3. Encourage the client Helps the client
to participate in to develop a
activities that more positive
promote self- body image.
acceptance and self-
esteem. One
example is
journaling, this
involves writing
strengths and
accomplishments
and positive
qualities that may
help the individual
recognize their
worth and build up
positive self-image.
Makes the
4. Reframe negative client focus on
thoughts about the the positive
client's body. This aspects of his
includes helping appearance.
the patient build a
support network of
friends, family, or
support groups
where they can
share their
experiences and
receive
encouragement
and understanding
Help the client
5. Encourage the to feel more in
client to set realistic control of his or
goals for body her body image
image improvement
NURSING CARE PLAN FOR HYPERTHERMIA
IMPLEMENTATION
ASSESSMENT DIAGNOSIS PLANNING EVALUATION
INTERVENTION RATIONALE
Objective Data: Hyperthermia Following the Independent: Goal Met.
Elevated related to implementation At the end of
body infection as of nursing Monitor vital Helps to assess the nursing
temperature evidenced by interventions, it signs and severity of intervention, the
(38. 4 C) elevated is expected that patient’s level hyperthermia and patient is able to
body the patient will of identify its early manifest core
temperature demonstrate consciousness complications body temperature
maintenance of regularly. withing normal
core body limits.
temperature
within the Provide cooling By using a fan to blow
established measures directly onto the
normal range. (e.g., tepid patient and also
sponge bath, spraying or sponging,
applying ice you can accelerate the
packs: to the rate of evaporation
groin, axillae, and thereby lower the
and neck) body temperature
more quickly.
Patient To dispel common
Education myths and
about the misconceptions about
misconceptions hyperthermia. For
regarding example, some people
hyperthermia believe that fever is
always a good
thing, or that it is
necessary to "sweat
out" a fever. These
misconceptions can
lead to delays in
seeking
treatment, which can
put patients at risk.
Encourage the This will prevent
patient to drink dehydration, which
plenty of fluids may worsen
hyperthermia
Dependent:
Administer To help reduce fever
antipyretics as and to efficiently apply
prescribed by health care through
the healthcare collaboration
provider
NURSING CARE PLAN FOR ACUTE PAIN
IMPLEMENTATION
ASSESSMENT DIAGNOSIS PLANNING EVALUATION
INTERVENTION RATIONALE
Objective Data: Acute pain Upon Independent: Goal Met.
Facial related to completion of Following the
grimacing impaired skin the nursing Evaluate the overall To determine a proper implementation
Pain scale integrity interventions, condition of the client’s and efficient health of nursing
(7 out of secondary to the patient is skin. Assess skin color, care necessary for the interventions,
10) cellulitis anticipated to moisture, texture, patient’s case. the patient
experience temperature. Take note demonstrates
alleviation of of any erythema, relief from pain.
symptoms. edema, and tenderness.
Adhere to the Aseptic techniques is
physician's guidance in necessary for wound in
cleansing the wound, order to reduce the risk
providing for infection and may
comprehensive also lessen the
education to both the triggering factors of
patient and their family pain.
regarding appropriate
wound care procedures.
Facilitate adherence to Facilitating adherence
skin care regimens to skin care regimens
aimed at minimizing aimed at minimizing
skin irritations, skin irritations,
employing lukewarm employing lukewarm
water and the use of water and the use of
gentle cleansers such gentle cleansers such
as mild soap or non- as mild soap or non-
soap alternatives to soap alternatives to
mitigate the risk of mitigate the risk of
irritations. irritations
Changes in lifestyle
Educate the patient are recommended to
about the aggravating lower the risk of
factors that should be triggers.
avoided.
Dependent:
Give pain reliever as To alleviate pain
doctor’s order
