NURSING CARE PLANS

NURSING STANDARD

S:
O: POST OP SURGICAL WOUND CRANIOTOMY
A: Impaired skin integrity
P: Within 8 hours of providing
nursing interventions, the client will:
the client will achieve optimal wound healing
as manifested by wound closure and no
evidence of infection.
I: Change wound dressing using the topicals and
dressing materials ordered, at the prescribed
frequency.
Frequently reassess the integrity of the dressing.
Reinforce dressing as needed. Monitor for change
in amount, type, odor and frequency of drainage
and need for reinforcement.
During the first 24-48 of injury continually assess
the injury for evidence of adequate perfusion,
edema and depth of injury. Check capillary refill,
pulses (via palpation or Doppler ultrasound) every
hour or as ordered.
With each dressing change maintain sterile
technique.
Monitor client's continence status and minimize
exposure of skin impairment site and other areas to
moisture from incontinence, perspiration, or wound
drainage.

S:
O: Inability to feed self
independently
Inability to dress self independently
Inability to bathe and groom self
independently
Inability to perform toileting tasks
independently
Inability to ambulate independently
A: Self-Care Deficit in
bathing /hygiene, dressing
/grooming, feeding and toileting
P: Within 8 hours of providing
nursing interventions, resources will
be identified which are useful in
optimizing the autonomy and
independence
I: Place patient in optimal position
for feeding
Provide privacy during dressing.
Provide frequent assistance as
needed with dressing.
Use of clothing one size larger.
Maintain privacy during bathing as
appropriate.
Assist patient in removing or
replacing necessary clothing.

DATE/TIME

FOCUS

DAR

S:
O: Right leg wound, Facial grimace,
guarding, numbness, pain: pain
scale
rated at 7/10 & 8/10.

A: Pain
P: Within 1 hour of providing nursing
interventions, the patient will report
pain relieved/controlled. Appear
relaxed, able to rest/sleep.
I: Provided with diversional activity
e.g talking with the patient.
Maintained immobilization of
affected part by means of bed rest.
Encouraged patient to verbalized
concerns
Instructed not to move/touched the
affected part.
Provided emotional support and
encouraged to perform deep
breathing exercises