Republic of the Philippines
SULTAN KUDARAT STATE UNIVERSITY
EJC Montilla, City of Tacurong, 9800 Province of Sultan Kudarat
Name of Patient: L. G. L. Age/Sex: 80/ Male
Initial/ Admitting Diagnosis: TO CONSIDER SEPTIC SHOCK 2° TO CAP HIGH RISK R/O CEREBROVASCULAR ACCIDENT BLEED
NURSING CARE PLAN
NURSING
ASSESSMENT PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Impaired Skin In 10 hours of 1. Introduce yourself at the 1. This will establish trust in the GOAL PARTIALLY MET
Integrity intervention the start of the nursing care. working phase. After 10 hours of intervention
Related to client will be able 2. Elderly patient’s is less elastic and the client was able to:
Age, to: 2. Determine the risk factors has less moisture making it more The patient received
Immobility, leading to pressure ulcer prone to skin impairment. timely medical
Friction or receive formation: age, disease, 3. The areas where the skin is attention, preventing
05/13/2024 shear, poor proper mobility stretched are as follows: sacrum. worsening of the
(08:00 am) circulation, medical Trochanters, scapulae, elbows. These condition.
3. Observe the skin integrity
moisture, attention on the bony prominences. are the areas where the highest skin The patient showed
Objective: chronic before it breakdown is. There is a possibility of signs of healing with
Edema & disease state 4. Apply prescribed dressing skin ischemia due compression of
gets reduced redness and
swelling as evidence such as hydrocolloid blood vessels.
worse. swelling in pressure
Skin by redness, dressing. 4. This composition will prevent
manifest ulcers. However,
discoloration ulcer sores, signs of 5. Prevent over exposure to friction or shear. Another way is to complete healing of
Redness blisters, and healing moisture such as from urine provide emollient to skin to moisturize pressure ulcers has
Blisters lesions. and or perspiration. the skin. not yet been
Open lesion reduction 5. This can prevent accumulation of achieved. Pressure
6. Observe sterile technique
involving the of bacteria thereby keeping away from ulcer size reduced by
in doing procedures.
dermis pressure infection. 50%.
drainage of ulcers. 7. Hydrate the patient and 6. Foreign body can also affect greatly family adhered to
pus. prevent encourage intake of foods the capability of the skin to repositioning the
Skin peeling future rich in Vitamin C and protein. regenerate. Keeping the area clean patient but, new
pressure and free from excessive moisture can ulcers still developing.
ulcer lead to faster healing process.
7. Collagen can come from Vitamin C,
eating lots of food rich in Vitamin C
can replace the lost collagen thereby
leading to faster healing process.
Republic of the Philippines
SULTAN KUDARAT STATE UNIVERSITY
EJC Montilla, City of Tacurong, 9800 Province of Sultan Kudarat
Name of Patient: L. G. L. Age/Sex: 80/ Male
Initial/ Admitting Diagnosis: TO CONSIDER SEPTIC SHOCK 2° TO CAP HIGH RISK R/O CEREBROVASCULAR ACCIDENT BLEED
NURSING CARE PLAN
NURSING
ASSESSMENT PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
05/14/2024 Ineffective In 10 hours of •Monitor vital signs. To have a baseline data. GOAL
(08:00 am) airway intervention the •Assess respiratory rate. Provides a basis for evaluating adequacy PARTIALLY
Objective: clearance client will be able •Asses airway patency. of ventilation. MET
Pale skin related to to: •Position the patient upright if Maintaining patent airway is always the After 10 hours of
Cyanosis excessive Demonstrate tolerated. Regularly check the first priority, especially in cases like trauma, intervention the
Facial mucous absence/reduction patient’s position to prevent acute neurological decompensation, or client was able
grimacing secretion of congestion with sliding down in bed. cardiac arrest. to:
Lethargy as breath sounding •Explain to the patient’s family Upright position limits abdominal contents Improve
Fatigue evidenced clear, noiseless the effects of contributing from pushing upward and inhibiting lung in oxygen
Presence of by respirations, and factors to lung problems. expansion. This position promotes better exchange,
crackles upon crackles improve oxygen •Document response to drug lung expansion and improved air exchange. however,
auscultation and exchange. therapy and/or development of Teaching about smoking cessation or excessive
desaturatio adverse side effects or other factors affecting ventilation is vital for mucus,
VS as follows:
n airway interactions with antimicrobials, the patient’s recovery. Avoiding allergens crackles
Temp: 37.2 C
steroids, expectorants, and or other irritants may reduce sound is
PR: 80bpm
bronchodilators. bronchospasms and other respiratory still
RR: 15cpm
•Check drug dosage, route problems. observed.
BP:97/53
frequency, expiration date. Pharmacological therapy is used to
mmHg
•Institute airway suctioning as prevent and control symptoms, reduce
O2 Sat: 98%
indicated based on the severity of exacerbations, and improve
Glasgow
presence of adventitious breath health status.
Coma
sounds and/or increased
Scale: 7 To ensure that the patient receive proper
ventilatory pressure.
medication administration.
The frequency of suctioning should be
based on the client’s clinical status, not on
a preset routine such as every2 hours.
Over suctioning can cause hypoxia and
Republic of the Philippines
SULTAN KUDARAT STATE UNIVERSITY
EJC Montilla, City of Tacurong, 9800 Province of Sultan Kudarat
injury to bronchial and lung tissue.
