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click here for freelancing tutoring sitesNURSING CARE PLAN FOR IMPAIRED SKIN INTEGRITY

ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION EVALUATION

Subjective:“Ang dami ng sugat niya sa bibig” – as verbalized by the mother

Objective:*Erythmatous wounds around the mouth*Disruption of skin surface on

mouth*Destruction of skin layer bother epidermis and dermis

Impaired skin integrity r/t erythmatous wounds on mouth secondary to Aphthous Ulcer

Definition: Altered epidermis and/or dermis.

Background Theory: According to Florence Nightingale the environmental sanitation and proper hygiene plays a vital role in a patient’s healing process, with this, nursing care must focus on manipulating the environmental sanitation and improving or enhancing patient’s hygiene.

STG:At the end one (1) hour nursing interventions, patient will be able to:

*Be free from further complications.*Be free from developing more ulcers.

LTG:At the end of one (1) month nursing interventions, patient will be able to:

*Demonstrate timely healing of erythamous wounds without complication.

Independent:1) Establish rapport. R: To gain cooperation and trust2) Ascertain attitudes of mother about condition, note for misconceptions. R: Identifies areas to be addressed in teaching plan, and potential referral.3) Keep area clean, dry, carefully dress wounds. R: To avoid complications.4) Provided health teachings to mother: >Nutrition: ~Instructed to avoid eating spicy and hot foods. R: This may lead to aggreviating the ulcer further. ~Instructed to eat foods that are soft, but rich in vitamins and minerals. R: Soft foods will be easy to eat thus not touching the wounds and will not provide more aggreviation to the ulcer. >Fluids: ~Instructed to avoid intake of hot

fluids. R: Hot fluids will cause more pain to the ulcer.Dependent:5) Administered antibiotics as prescribed. R: To provide prophylaxis and to control infection.6) Monitor and regulate IVF. R: To maintain adequate hydration.Collaborative: 7) Refer to nutritionist and dietician on appropriate foods and what to avoid. R: To have proper food and fluid intake.

STG:After one (1) hour of nursing interventions, goal was partially met as evidenced by:

*(-) to complications.*Afebrile

LTG:After one (1) month of nursing interventions, goal was successfully met as evidenced by:

*Erythmatous wounds are healed*No further ulcers were developed.

NURSING CARE PLAN FOR RISK FOR IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS

ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION EVALUATION

Subjective:“Hindi na siya kumakain masyado ng solid foods, at di na niya nauubos isang bote ng gatas simula ng dumami sugat niya sa bibig” – as verbalized by the mother

Objective:*Erythmatous wounds around the mouth*Slightly paled conjunctiva*Consumed only 3 oz. of 8 oz. served milk*loss of appetite

Risk for imbalanced nutrition: less than body requirements r/t difficulty of intaking food and fluids r/t Apthous ulcer

Definition: At risk of intake of nutrients is insufficient to meet metabolic needs.

Background Theory: According to Virginia Henderson’s theory of 14 human needs, it is stated that a person’s nutrition must be adequate to achieve optimum level of homeostasis.

STG:At the end one (1) hour nursing interventions, patient will be able to:

*Be able to consume 8oz. of milk during shift.

LTG:At the end of one (1) month nursing interventions, patient will be able to:

*Demonstrate progressive intake of food.

Independent:1) Establish rapport. R: To gain cooperation and trust2) Assist in providing oral care. R: To improve patient’s taste.3) Clean the area and avoid malodorous stimulus. R:To avoid patient’s loss of appetite 4) Provided health teachings to mother: >Nutrition: ~Instructed to avoid eating spicy and hot foods. R: This may lead to aggreviating the ulcer further. ~Instructed to eat foods that are soft, but rich in vitamins and minerals. R: Soft foods will be easy to eat thus not touching the wounds and will not provide more aggreviation to the ulcer. >Fluids: ~Instructed to avoid intake of hot

fluids. R: Hot fluids will cause more pain to the ulcer.Dependent:5) Administered antibiotics as prescribed. R: To provide prophylaxis and to control infection.6) Monitor and regulate IVF. R: To maintain adequate hydration.Collaborative: 7) Refer to nutritionist and dietician on appropriate foods and what to avoid. R: To have proper food and fluid intake.

STG:After one (1) hour of nursing interventions, goal was partially met as evidenced by:

Subjective:“Naintindihan ko, lagi ko na gagawin ang mga yan.”

Objective:*Oral care was done to patient by mother as seen in ward.*Patient consumes a total of 6 oz. during shifr.

LTG:After one (1) month of nursing interventions, goal was successfully met as evidenced by:

*Patient eats regularly and consumes food fully.

NURSING CARE PLAN FOR READINESS FOR ENHANCED KNOWLEDGE: PREVENTION OF REOCCURRENCE OF ULCERS

ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION EVALUATIONSubjective:“Maam, ano po yung mga kailangan ko gawin para hindi na ito lumala pa o magkaroon ulit?”-as verbalized by mother

Objective:

*Curious*Activily ask queries about the disease

Readiness for enhanced knowledge: Prevention of reoccurence of ulcers r/t erythamous lesions secondary to Apthous ulcers.

Definition: The presence or acquisition of cognitive information related to a specific topic is sufficient for meeting health-related goals and can be strengthened.

Background Theory: According to Nola J Pender, Health promotion is directed at increasing a client’s level of well being. The health promotion model describes the multi dimensional nature of persons as they interact within their environment to pursue health. Therefore nursing actions must focus on health promotion

STG:At the end one (1) hour nursing interventions, patient’s mother will be able to:

*Verbalize understanding of health teachings

LTG:At the end of one (1) month nursing interventions, patient will be able to:

*Demonstrate lifestyle changes that prevents reoccurrence of apthous ulcer to child.

Independent:1) Establish rapport. R: To gain cooperation and trust.2) Provided health teachings to mother: >Nutrition: ~Instructed to avoid eating spicy and hot foods. R: This may lead to aggreviating the ulcer further. ~Instructed to eat foods that are soft, but rich in vitamins and minerals. R: Soft foods will be easy to eat thus not touching the wounds and will not provide more aggreviation to the ulcer. >Fluids: ~Instructed to avoid intake of hot

fluids. R: Hot fluids will cause more pain to the ulcer. >Environment: ~Assisted in cleaning the room and provided adequate ventillation. >Hygienic Care: ~Demonstrated proper handwashing technique. ~Instructed to do daily bath ~Assisted to do oral care to patient.3)Provided health teachings to mother on how to acquire apthous ulcer. R: To avoid triggers.

STG:After one (1) hour of nursing interventions, goal was partially met as evidenced by:

Subjective:“Salamat, naiitindihan ko, alam ko na ngayon kung ano mga dapat iwasan.”

Objective:

*Oral care done as seen in ward.*Proper handwashing technique done as seen in the ward.

NURSING CARE PLAN FOR ACUTE INTERMITTENT PAIN

ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION EVALUATIONSubjective:

“Sakit mama” (while pointing to mouth)

*Pain Scale: 6/10*Quality:Throbbing

*Frequency: Inter-

mittent -as per mother’s description

Objective:*With erythmatous wounds aroung mouth*Crying*Frowning*Pointing to ulcers

Acute intermittent moderate pain r/t presence of ulcers around mouth

Definition: Unpleasant sensory & emotional experience rising from actual or potential tissue damage.

Background Theory: According to Virginia Henderson, It is one of the 14 needs of the client is to be free from pain and be safe at all times.

STG: At the end of eight (8) hours nursing intervention, client will be able to:

*Manifest a decrease in pain*Demonstrate use of relaxation techniques & other diversional activities.

Independent: *Provide bedside care.R: Bedside care helps in making the environment clean and pleasing to the eyes & feeling of the patient, thereby decreasing pain and promoting comfort.

* Provide diversional activities such as playing and listening to music.R: Diversional activities and relaxation techniques provides a refreshing feeling and effective way of diverting client’s attention to pain independently.

*Instruct client to avoid moving as much as possible if unnecessary.R: Moving frequently that is unnecessary will cause pain to the patient.

Dependent: *Administer pain reliver as prescribed.R: Prescribed pain relivers aids in alleviating the pain of the patient.

STG:After one (1) hour of nursing interventions, goal was partially met as evidenced by:

*Patient slept.

NURSING CARE PLAN FOR RISK FOR INFECTION

ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION EVALUATIONSubjective:“Ang dami ng sugat niya sa bibig” – as verbalized by the mother

Objective:*Erythmatous wounds around the mouth*Disruption of skin surface on

mouth*Destruction of skin layer bother epidermis and dermis

Risk for infection r/t damage of primary line of defense: skin

Definition: At increased risk for being invaded by pathogenic microorganisms.

Background Theory: According to Florence Nightingale the environmental sanitation and proper hygiene plays a vital role in a patient’s healing process, with this, nursing care must focus on manipulating the environmental sanitation and improving or enhancing patient’s hygiene.

STG: At the end of one (1) hour nursing intervention, client will be able to:

*Verbalize understanding of individual causative/risk factors to infection.

*Identify interventions to prevent risk of infection

*Maintain normal vital signs.

Independent:1) Establish rapport. R: To gain cooperation and trust

2) Keep area clean, dry, carefully dress wounds. R: Pathogenic Microogranisms thrive in moist environment.

3) Provide bedside care.R: Bedside care helps in making the environment clean and conducive to healing process thereby preventing acquisition of pathogenic microorganisms that causes infection.

4) Provide wound dressingR: Wound dressing will keep the ulcer free from infection.

5)Provided health teachings to mother: >Nutrition: ~Instructed to avoid eating spicy and hot foods. R: This may lead to aggreviating the ulcer further. ~Instructed to eat foods that are soft, but rich in vitamins and minerals. R: Soft foods will be easy to eat thus not touching the wounds and will not provide more aggreviation to the ulcer. >Fluids: ~Instructed to avoid intake of hot

fluids. R: Hot fluids will cause more pain to the ulcer.

Dependent: 6) Administer antibiotics as prescribed. R: Antibiotics prevents development of infection

7) Monitor and regulate IVF. R: To maintain adequate hydration.

STG:After one (1) hour of nursing interventions, goal was partially met as evidenced by:

*(-) to complications.*Afebrile

LTG:After one (1) month of nursing interventions, goal was successfully met as evidenced by:

*Erythmatous wounds are healed*No further ulcers were developed.

Collaborative: 7) Refer to nutritionist and dietician on appropriate foods and what to avoid. R: To have proper food and fluid intake.