Nursing Care Plan

Student Name/Date: ____________Mark Doherty 10/3/07______________


Nursing Diagnosis
(Dx, related to, & as evidenced by)
Knowledge deficit of management
of visual impairment related to
patient being unfamiliar with facial
cellulitis as evidenced by the patient
and spouse asking about what needs
to be done to manage the cellulitis
and what kind of assistance the
patient may need .
Expected Outcomes
(Short term (8-48 hr.) reasonable
expectations stated in measurable,
behavioral terms, i.e., action
verbs)
Patient and spouse will understand
that patient will need assistance
with ADLs (toileting, eating,
walking, taking meds) by end of
shift.
Patient and spounse will state 3
techniques to manage cellulitis by
discharge
Nursing Interventions/Rationale Outcome Evaluation
List all interventions for each nsg. dx (include (Patient outcome noted as met or
patient/family teaching) unmet/responses described)
1. Assess readiness to learn management Met. Patient and spouse understand
techniques of cellulitis from the patient that patient will need help with
and spouse. It needs to be made sure ADLs. Asked questions to clarify
that the patient and spouse are willing and backbriefed my teaching.
to learn these interventions so they can
apply them. Met. Patient and spouse said they
2. Explain to spouse to clear obstructions understand and stated at least 3
along his path when ambulating. This techniques in managing the
reduces chance of falls (Harkreader and cellulitis.
Hogan, 2004, p. 988)
3. Explain to spouse that rooms at home
should be well or brightly lit. This
prevents chance of pt. bumping into
things and injuring self and falling.
(Harkreader and Hogan, 2004, p. 988)
4. Explain to spouse that she needs to give
medications to client. Since his vision is
hindered, his wife is the only one who
can read the label for the correct meds.
5. Collaborate with dermatologist or
wound-care nurse to find ways to treat
and manage symptoms of cellulitis
(mainly the inflammation) that can be
used to teach the patient and spouse.
Dermatoligist and wound care nurse
can find other methods of treamtent and
possible medications.
6. Teach patient to moisturize skin to
prevent cracking and peeling. Cracks
and peels serve as portals of entry of
bacteria and this can lead to
complications such as cellulitis.
(http://www.mayoclinic.com, 2007)
7. Tell patient, when resting, to try to sit at
90 degrees with head straight to
promote maximum venous return to
prevent venous stasis. Venous stasis is a
risk factor for cellulitis. (Venes, 2005,
p. 373)
8. Teach patient and spouse to apply cold
(i.e.ice pack) if sympotms get worse
(increase in swelling and pain) Cold is a