NURSING CARE PLAN

Assessment:
CUES & CLUES NURSING Scientific Rationale Client Outcome Nursing Intervention Rationale Evaluation
Signs and Symptoms DIAGNOSIS Planning

Subjective Cues: Problem: Deep wound Short term: Teach the client for Early assessment After 8 hours of
Impaired Skin | skin assessment and and intervention nursing intervention
Objective cues: Integrity r/t to | Client will be able to ways for monitor skin helps prevent the the client will be able
surgery Dry skin report any altered breakdown. development of to look for and how
• Patient has | sensation or pain on serious problem. to inpect her legs
deep wound | left lower extremity. and will be able to
on the lower Necrosis demonstrate a self
left leg. | Monitor skin Inspection can inspection of his
• Patient skin is | condition at least identify impending lower extremity and
flaky and very Surgery once a day for color problems early. able to report pain.
dry. or lesion.
• Patient looks
weak and
tired. Long term: The patient is able to
Limit the number Excessive bathing identify what body
Verbalize a Personal complete baths to 2 especially in hot part is at most risk
plan for preventing or 3 per week and water, depletes again for skin breakdown .
impairs skin integrity. alternate them with skin of moisture and He will also be taught
partial bath. increase dryness. how to do a
simplified skin
assessment and
what to look for if
there is skin
breakdown.
Assessment:
CUES & CLUES NURSING Scientific Rationale Client Outcome Nursing Intervention Rationale Evaluation
Signs and Symptoms DIAGNOSIS Planning

Subjective Cues: • Risk for Open wound Short term: • Perform daily • to clean the After 8 hours of
infection | wound care wound and to nursing intervention
Objective cues: related to | After 8 hours of • Give daily avoid infection the client is less at
tissue Bacteria enters the nursing intervention meds • to improve risk for infection and
• Pt. has deep destruction wound. the patient is less • Let the client/ condition and more knowledgeable
wound in the | risk for infection. client’s friends wound in wound care and
lower left leg | or relative to healing. more aware when it
with pus & Infection. Long term: observe and • For the patient comes to infection.
same participate in to be able to
secreations After 3 days the doing wound continue
patient is able to do care. wound care at
own wound care, • Brief the client home.
knows more when it more about • For the patient
comes to preventive how to to avoid and
measures to infection prevent further to do certain
and manifesting infection. (e.g. things to avoid
good/better wound good hygiene, infection and
healing. clean to promote
environment & fast/good/bett
etc.) er wound
healing
Assessment:
CUES & CLUES NURSING Scientific Rationale Client Outcome Nursing Intervention Rationale Evaluation
Signs and Symptoms DIAGNOSIS Planning

Subjective Cues: Risk for infection RT Short term: Note risk factors of To evaluate the After 3 days of
tissue destruction Open wound After 30 mins. Of occurrence of presence of infection nursing intervention
Objective cues: with increase | nursing intervention infection all the interventions
environmental | the patient will were met which was
• Awake on bed factors Bacteria enters the verbalize Observe for localized To evaluate the made evident by the
• Open wound wound. understanding and signs of infection at presence of infection absence of signs and
on left lower | willingness to follow wounds symptoms related to
extremity | up prescribe infection.
• Yellowish Infection. regimen. Administer and To determine
secretion on instruct precautions effectiveness of the
wound Long term: regarding medication therapy and if there
• Both legs has regimen and note is a presence of side
scars and After 3 days of clients response effect
scabs nursing intervention
• With heplock the patien will be free Emphasize necessity To inform the client
from signs and of taking antibiotics the risk for
• Ambulatory
symptoms related to as directed discontinuation of
(partially
infection. treatment
assisted)
• Wound
Review To assess if there is
dressing intact
environmental a need of avoidance
factors or modifications of
the environment to
reduce incidence of
infection.