Nursing Care Plan Sample (student Made)

Assessment Diagnosis Subjective: “May mga sugat ako.” as verbalized by the patient. Objective: ~Disruption of skin surface at the right upper arm ~presence of pain ~the wound is 7mm in distance ~there has a presence of erythema ~presence of itchiness in the surrounding of the wound

~Impaired skin integrity related to inflammatory response secondary to infection.

Planning Goal: After the nursing 3 days intervention the client will be able to display improvement in wound healing. Objective: ~the wound will be lessen in diameter ~there will be an absent of erythema ~the presence of wound will be minimize ~absence of itchiness

Intervention Rationale

~Demonstrated good skin hygiene (ex. wash thoroughly and pat dry carefully) ~provide and applied wound dressing carefully ~Emphasized importance of adequate

~Maintainin g clean, dry ~the goal is skin provides met. a barrier to infection. Because the client is able to display improvement in wound healing as evidence by ~ Wound minimized dressings presence of protect the wound. wound and ~there s a the absent of surrounding itching tissues ~absent of ~ Improved pain nutrition and ~several part hydration of wound had will improve dried up. skin condition.

nutrition and fluid intake. -clean the wound with disinfectant and avoid using dirty dressing

Evaluation

~so the wound will be not infected

Assessment Subjective: “The client verbalize that she has experiencing pain upon urinating and their foulsmelling urine Objective: ~Restlessness ~Pain in the client’s back just below the rib cage, on one side of her body ~cloudy urine in urine examination

Diagnosis Dysuria related to infection.

Planning

Interventio n

Goal: After the intervention the client will be able to urinate with out pain

~promote proper hygiene (wash the anal and perennial area with soap and water daily)

Objective: ~absent of foul smell ~promote when fluid intake urinate ~absent of cloudy urine

Rationale

Evaluation

~ to avoid The goal is infection and met. contamination Because the to bacteria. client is able to urinate with out pain. the client didn’t feel pain in her back just ~it will help below the to flush or to rib cage, on get the one side of bacteria away her body in the urinary system.