NURSING CARE PLAN
Name of Patient: Mrs. S Attending Physician: Dr. A.A.S
Age:61 Area/Ward/Bed Number: Medical Ward Impression/Diagnosis:
Objectives of Care +
Rationale Outcome Criteria Rationale
Clustered Cues Nursing Diagnosis (Scientific Basis) (Subject + Verb + Nursing Interventions (Scientific Basis) Evaluation
condition + Criteria +
Target Time)
Date &Time: May 22, Impaired Skin The impaired skin General: Independent: Independent: Date & Time: May 22,
2024; 10:15 AM Integrity related to integrity in Mrs. S is ● Monitor vital ● Vital signs can 2024; 6:15 PM
Pressure over bony primarily due to After the nursing signs. indicate if there is
pressure, immobility, intervention, the patient will ● Ensure that the any improvement in The patient showed
prominence as
Subjective: the patient’s state or
evidenced by a 17 and environmental be able to alleviate pain and patient has
if there are
improvement in the
factors, leading to pressure in the lower back, supportive management of bed
The patient, Mrs. S, cm by 14 cm lesion stage 2 pressure deviations from
on the lower back, a ulcers on her left foot, gluteus maximus, and left surfaces to sores and ulcers.
reports significant normal.
discomfort and pain when 5 cm lesion on the lower back, and phalanges (I) mediae, prevent pressure
● Supportive surfaces
repositioned. Dealing buttocks, and a prevent further irritation of ulcers.. After 8 hours of nursing
buttocks. These distribute pressure
significant discomfort as stage 2 pressure bed sores, maintain good ● Reposition the intervention, there was
ulcers result from evenly, reducing the
she has to put pressure on hygiene practices to prevent patient regularly, risk of pressure a reduction in the size
ulcer on the left foot. prolonged pressure
her back, leading to pain infection, and promote every 2 hours, to ulcers and and appearance of the
Pain and discomfort on bony
prominences, healing of bed sores prevent skin promoting tissue bed sores and ulcers.
C: Sharp and throbbing noted during
exacerbated by lack through proper wound care. breakdown. perfusion. The patient's pain
pain repositioning and
of movement and ● Assist patient ● Regular intensity decreased
range of motion with hygiene: from 8/10 to 6/10 within
repositioning
O: Began a few weeks exercises. Limited exposure to Ensure regular alleviates pressure 8 hours, indicating
prior to admission, but pollutants. Adequate Specific:
mobility and difficulty nutrition, hydration, bathing, keep on vulnerable improved pain
worsened during
sitting or lying ● Patient reports a
admission to hospital. infection reduction in pain skin dry, and areas, preventing management.
comfortably due to management, and change skin breakdown and Additionally, no signs of
intensity in the lower
L: Lower back (lesion size: pain and sores. pain relief are crucial back and gluteus bedding/clothing ulcer formation. infection were observed
17 cm height and 14 cm Weakness and for promoting skin maximus from 8/10 promptly to ● Good hygiene in the wounds, and the
width) fatigue present. healing and overall to 4/10 within 24 prevent infection practices reduce patient reported
Buttocks (lesion size: 5 well-being. hours of intervention. and aid in the infection risk and increased comfort
cm) ● No new bed sores support wound
healing of bed during repositioning and
Left foot (stage 2 pressure are observed, and healing by
sore) Definition: NANDA sores and foot movement. However,
existing bed sores maintaining clean
ulcers. complete healing of the
D: Constant pain, worsens Pressure ulcers are show signs of ● Follow proper skin and preventing wounds were not
with movement and localized injuries to improvement wound care bacterial achieved within the
contact with surfaces, i.e. the skin and/or (reduced redness, protocols for bed colonization. timeframe, indicating
bed underlying tissue swelling, or sores, including ● Proper wound care partially met goals.
usually over a bony drainage) within 48 gentle cleaning creates an optimal
S: 8 out of 10 on the pain prominence, as a hours. healing
scale
with mild soap
result of pressure, or ● Patient reports and water, environment,
pressure in increased comfort applying removing debris,
P: Pain worsens during combination with during repositioning protecting the
movement and when appropriate
shear and/or friction. and movement wound, and
pressure is applied to dressings, and
This condition is within 24 hours. facilitating tissue
affected areas changing
often associated with ● No signs of infection repair.
dressings as
A: Weakness and fatigue, immobility and other (e.g., redness,
needed to
● Early detection of
Severe limitation in factors that warmth, discharge) infection prevents
maintain a clean
performing daily activities compromise skin are observed in bed complications,
integrity and tissue sores within 48 and moist wound allowing prompt
perfusion. Also hours. environment intervention to
Objective: defined as an ● Visible reduction in conducive to control infection and
● Skin Integrity: alteration of the size and improvement healing. prevent further
Stage 2 pressure epidermis/dermis. in the appearance of ● Regularly assess tissue damage.
ulcer on left foot, bed sores observed the bed sores for ● Education
Lesion on lower within 1 week. signs of empowers
back: 17 cm infection, such individuals to
height, 14 cm as increased participate in their
width, Lesion on redness, care, promoting
buttocks: 5 cm in swelling, adherence to
diameter, warmth, or preventive and
Presence of drainage, and treatment measures
visible skin report any and optimizing
breakdown with changes to the healing outcomes.
partial-thickness healthcare
provider for Dependent:
skin loss on the (Dependent, Interdependent)
left foot further ● Paracetamol IVT
evaluation and effectively alleviates
● Pain Response: treatment. pain associated with
● Educate the bed sores,
Exhibits patient and enhancing patient
discomfort and
pain during family members comfort and
repositioning and on the promoting rest.
range of motion importance of Intravenous
exercises proper administration
positioning, skin ensures a rapid
● Mobility: Limited care, and wound onset of action,
ability to sit or lie care techniques particularly
comfortably due to prevent further beneficial for
to bedsores. skin breakdown patients
Restricted experiencing
and promote
movement due to significant pain.
healing of the
pain and sores. ● Ceftriaxone IVT
bed sores. addresses
● General
infections
Appearance: commonly
Weakness and associated with bed
fatigue observed sores, targeting
Dependent: bacterial pathogens
● Administration of to prevent systemic
Paracetamol spread and
300mg IVT every complications.
4 hours PRN for Intravenous
pain relief administration
associated with ensures systemic
bed sores. delivery, optimizing
● Administration of therapeutic efficacy
Ceftriaxone 2gm and promoting
IVT OD for the wound healing.
treatment of
infections
associated with
bed sores.
DRUG STUDY
Name of Patient: Attending Physician:
Age: Area/Ward/Bed Number: Impression/Diagnosis:
Name of Drug Dosage/Route/ Mechanism of Action Indication Adverse Reactions Special Precautions Nursing
Frequency/Timing Responsibilities
Generic Name: Dosage:
Brand Name: Route:
Classification Frequency: Contraindications Side Effects
Timing:
