7/21/2019 Nursing Care Plan for Cellulitis

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Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNIG INTERVE

NTION

EVALUATION

S : Namamagaat namumula ang

kanang paa ko.As verbalized by

the patinet.

O :

-swelling of theright foot

-skin redness-skin lesions

Impaired skinintegrity related

to bacterialinfection asmanifested by

the swelling ofthe right foot.

SHORTTERM GOAL

:After 4 hoursof rendering

nursingintervention,

patient will beable to

participate inpreventivemeasures and

treatmentprogram.

LONG TERMGOAL:

After 1 week

the client willbe taught whata part of his

body is at mostrisk for skin

break down

INDEPENDENT :

>Identifyunderlyingcause/condit

ioninvolved.

>Notechanges inskin color,texture and

turgor.

>Determinedepth of

injury/damage to

integumentary system.

>Inspectskin on a

daily basis,describinglesions and

changesobserved.

>Keep theareaclean/dry,

prevent

infection,and

stimulatecirculationto

surroundingareas.

>Reviewimportance

of skin and

To assesscausative/contributing

factors.

To assessextent ofinvolvement/injury.

To assessextent of

involvement/injury.

To assist withcorrecting/min

imizingcondition and

promote

optimalhealing.

To assistbodys naturalprocess ofrepair.

To promotewellness.

After 4 hours ofrendering

nursingintervention, theclients mother

participated inpreventive

measures andtreatment

programs for herchild.

After week ofteaching the

client, he is seendoing a self-inspection of his

lowerextremities.

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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S : Medyo ni-nerbyos na ako

ng makausap koang doctor. As

verbalized bythe patient.

-increasedalertness

-v/s taken asfollows :

P : 125 bpm

R : 22 cpm

Fear related tounfamiliarity

withenvironmental

experiences asevidenced byincreased

alertness.

After 8 hoursof rendering

nursingintervention,

the client willlessen hisfear.

INDEPENDENT :>Note degree of

incapacitation.

>Measure vital

signs/physiologicalresponses to situation.

>Stay with the client or

To assess

degree of fearand reality of

threatperceived bythe client.

To assess

degree of fearand reality ofthreat

perceived bythe client.

Sense of

After 8 hours ofrendering nursing

intervention,clients fear has

lessened.

measures to

maintainproper skinfunctioning.

>Discuss

importanceof earlydetection of

skinchangesand/orcomplications.

.DEPEDEN

T :>Assist

Nurse onduty in give

prescribed

IV meds asindicated.

To promotewellness.

To relieve

inflammation.

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make arrangements to

have someone else bethere.

>Identify clientspartner the

responsibility for thesolutions.

>Instruct patient in useofrelaxation/visualizationand guided imageryskills.

abandonment

can exacerbatefear.

Enhancessense of

control

Provides ahelpful andhealthy outletfor energygenerated by

fearfulfeelings and

promotesrelaxation.

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ASSESSMENT DIAGNOSIS PLANNIG INTERVENTION EVALUATION

S : Namamaga at

namumula angkanang paa ko.

As verbalized bythe patinet.

O :-swelling of the

right foot-skin redness-skin lesions

Impaired skin

integrity relatedto bacterial

infection asmanifested bythe swelling of

the right foot.

SHORT TERM

GOAL :After 4 hours

of renderingnursingintervention,

patient will beable to

participate inpreventivemeasures andtreatment

program.

LONG TERM

GOAL:

After 1 week

the client willbe taught what

a part of hisbody is at mostrisk for skin

break down

INDEPENDENT :

>Identify underlyingcause/condition

involved.R : To assesscausative/contributing

factors.>Note changes in skin

color, texture and turgor.R :To assess extent ofinvolvement/injury.>Determine depth ofinjury/damage to

integumentary system.R :To assess extent of

involvement/injury.>Inspect skin on a daily

basis, describing lesions

and changes observed.R :To assist with

correcting/minimizingcondition and promoteoptimal healing.

>Keep the areaclean/dry, prevent

infection, and stimulatecirculation tosurrounding areas.

R :To assist bodysnatural process of repair.

>Review importance ofskin and measures tomaintain proper skinfunctioning.R :To promote wellness.

>Discuss importance ofearly detection of skin

changes and/orcomplications.R : To promote wellness.

>Assist clients motherin understanding and

following medicalregimen and developing

program of preventive

care and dailymaintenance.R :Enhancescommitment to plan,

After 4 hours of

rendering nursingintervention, the

clients motherparticipated inpreventive

measures andtreatment programs

for her child.

After week ofteaching the client,he is seen doing a

self-inspection ofhis lower

extremities.

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Discharge Planning

Get plenty of rest. This gives your body a chance to fight the infection.

Raise the area of the body involved as high as possible. This will ease the pain, help

drainage and reduce swelling.

Please check the label for how much to take and how often. The pain eases once the

infection starts getting better.

optimizing outcomes.

DEPEDENT :>Assist Nurse on duty in

give prescribed IV medsas indicated.

R : To relieveinflammation.

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Be sure to take the full course of antibiotics.

You may be advised to make a follow-up appointment with your doctor to make sure the

cellulitis is improving. Dont forget to do this.