Sample Nursing Care Plan - Michigan Center for Nursing
Sample Adequate Nursing Care Plan (2 pages)
Work of 2nd Semester Junior Nursing Student
| | |Patient | | |Evaluation |
|Assessment |Nursing Diagnosis |Outcomes |Interventions |Rationale |of Outcomes |
|Objective Data: |#1: Impaired tissue integrity r/t |Patient will: |1. Monitor color, temp, edema, |1. Systematic inspection can |1. Surrounding skin remained |
|-Gangrene infected left foot |wound, presence of infection. |1. Report any altered sensation or|moisture, and appearance of |identify possible problem areas |intact and w/o inflammation. |
|-Open wound | |pain at site of tissue impairment |surrounding skin; note any |early in infection. | |
|-Wet to dry dressing | |during January 23 and 24. |characteristics of any drainage. | | |
|-Pain upon movement, grimacing, | | |2. Monitor site of impaired tissue| | |
|shaking | | |integrity at least once daily for | | |
|-She immediately requests Morphine| |2. Demonstrate understanding of |signs of infection. Determine |2. Pain secondary to dressing | |
|-She needs assistance when | |plan to heal tissue and prevent |whether patient is experiencing |change can be managed by |2. Wound did not have signs of |
|ambulating-even to sit up in bed | |injury by 1/24. |changes in sensation or pain. Pay |interventions aimed at reducing |added infection. |
| | | |attention to all high risk areas |trauma and other sources of wound | |
| | | |such as bony prominences, skin |pain. | |
| | | |folds, and heels. | | |
| | | |3. Monitor status of skin around | | |
| | | |the wound. Monitor patient’s skin | | |
| | | |care practices, noting type of | | |
| | | |soap or other cleansing agents | | |
| | |3. Describe measures to protect |used, temp of water, and frequency|3. Individualize the plan | |
| | |and heal the tissue, including |of cleansing. |according to patient’s skin | |
| | |wound care by 1/24. | |condition needs and preferences. |3. Educated patient on technique |
| | | | |Avoid harsh cleaning agents, hot |of cleansing and putting on |
| | | | |water, extreme friction or force, |dressing. Had her watch while I |
| | | | |and too frequent cleansing. |did it so she could understand. |
| | | | | |She stated she would try to do it |
| | | | | |herself when she is discharged. |
|Subjective Data: | | | | | |
|-Patient said the pain is worse | | | | | |
|when ambulating & turning | | | | | |
|-She said she dreads physical | | | | | |
|therapy | | | | | |
|-She said she wishes she did not | | | | | |
|have to be in this situation | | | | | |
|Medical Diagnoses: | | | | | |
|-Diabetes foot ulcer | | | | | |
|-Diabetes Mellitus Type 2 | | | | | |
|-PVD | | | | | |
|-Infection | | | | | |
| |Nursing Diagnosis |Patient | | |Evaluation of Outcomes |
|Assessment | |Outcomes |Interventions |Rationale | |
| | |4. Experience a wound that |4. Select a topical treatment that maintains a moist |4. Choose dressings that provide moist |4. Used wet to dry dressing, which was|
| | |decreases in size and has |wound –healing environment but also allows absorption|environment, keep skin around wound dry |changed twice a day. |
| | |increased granulation tissue. |of exudate and filling of dead space. |and control exudate and eliminate dead | |
| | | | |space. | |
| | |5. Achieve functional pain goal|5. Assess patient’s nutritional status; refer to | | |
| | |of zero by 1/24 per patient’s |nutritional consultation. |5. A good diet with nutritional foods and |5. She was on a clear fluid diet but |
| | |verbalizations. | |vitamins may help promote wound healing. |still has little appetite. Continued |
| | | | | |consultation with nutritionist before |
| | | | | |discharge would be beneficial. |
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