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NURSING CARE PLAN FOR IMPAIRED SKIN INTEGRITY
ASSESSMENT DIAGNOSIS

PLANNING

NURSING INTERVENTION

EVALUATION

Subjective:
Ang dami ng
sugat niya sa
bibig as
verbalized by
the mother
Objective:
*Erythmatous
wounds
around
the mouth
*Disruption of
skin surface on
mouth
*Destruction of
skin layer
bother
epidermis and
dermis

Impaired skin integrity


r/t erythmatous wounds
on mouth secondary to
Aphthous Ulcer

STG:
At the end one (1) hour
nursing interventions, patient
will be able to:

Definition: Altered
epidermis and/or
dermis.

*Be free from further


complications.
*Be free from developing
more ulcers.

Background Theory:
According to Florence
Nightingale the
environmental
sanitation and proper
hygiene plays a vital
role in a patients
healing process, with
this, nursing care must
focus on manipulating
the environmental
sanitation and
improving or
enhancing patients
hygiene.

LTG:
At the end of one (1) month
nursing interventions, patient
will be able to:
*Demonstrate timely healing
of erythamous wounds
without complication.

Independent:
1) Establish rapport.
R: To gain cooperation and trust
2) Ascertain attitudes of mother about
condition, note for misconceptions.
R: Identifies areas to be addressed in
teaching plan, and potential referral.
3) Keep area clean, dry, carefully dress
wounds.
R: To avoid complications.
4) Provided health teachings to mother:
>Nutrition: ~Instructed to avoid eating
spicy and hot foods. R: This may lead to
aggreviating the ulcer further.
~Instructed to eat foods that are soft, but
rich in vitamins and minerals. R: Soft
foods will be easy to eat thus not
touching the wounds and will not
provide more aggreviation to the ulcer.
>Fluids: ~Instructed to avoid intake of hot
fluids. R: Hot fluids will cause more pain
to the ulcer.
Dependent:
5) Administered antibiotics as prescribed.
R: To provide prophylaxis and to control
infection.
6) Monitor and regulate IVF.
R: To maintain adequate hydration.
Collaborative:
7) Refer to nutritionist and dietician on
appropriate foods and what to avoid.
R: To have proper food and fluid intake.

STG:
After one (1) hour
of nursing
interventions,
goal was partially
met as evidenced
by:
*(-) to
complications.
*Afebrile
LTG:
After one (1)
month of nursing
interventions,
goal was
successfully met
as evidenced by:
*Erythmatous
wounds are
healed
*No further ulcers
were developed.

NURSING CARE PLAN FOR RISK FOR IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS
ASSESSMENT DIAGNOSIS

PLANNING

NURSING INTERVENTION

EVALUATION

Subjective:
Hindi na siya
kumakain
masyado ng
solid foods, at
di na niya
nauubos isang
bote ng gatas
simula ng
dumami sugat
niya sa bibig
as verbalized by
the mother
Objective:
*Erythmatous
wounds
around
the mouth
*Slightly paled
conjunctiva
*Consumed
only 3 oz. of 8
oz. served milk
*loss of appetite

Risk for imbalanced


nutrition: less than
body requirements r/t
difficulty of intaking
food and fluids r/t
Apthous ulcer
Definition: At risk of
intake of nutrients is
insufficient to meet
metabolic needs.
Background Theory:
According to Virginia
Hendersons theory of
14 human needs, it is
stated that a persons
nutrition must be
adequate to achieve
optimum level of
homeostasis.

STG:
At the end one (1) hour
nursing interventions, patient
will be able to:
*Be able to consume 8oz. of
milk during shift.
LTG:
At the end of one (1) month
nursing interventions, patient
will be able to:
*Demonstrate progressive
intake of food.

Independent:
1) Establish rapport.
R: To gain cooperation and trust
2) Assist in providing oral care.
R: To improve patients taste.
3) Clean the area and avoid malodorous
stimulus.
R:To avoid patients loss of appetite
4) Provided health teachings to mother:
>Nutrition: ~Instructed to avoid eating
spicy and hot foods. R: This may lead to
aggreviating the ulcer further.
~Instructed to eat foods that are soft, but
rich in vitamins and minerals. R: Soft
foods will be easy to eat thus not
touching the wounds and will not
provide more aggreviation to the ulcer.
>Fluids: ~Instructed to avoid intake of hot
fluids. R: Hot fluids will cause more pain
to the ulcer.
Dependent:
5) Administered antibiotics as prescribed.
R: To provide prophylaxis and to control
infection.
6) Monitor and regulate IVF.
R: To maintain adequate hydration.
Collaborative:
7) Refer to nutritionist and dietician on
appropriate foods and what to avoid.
R: To have proper food and fluid intake.

STG:
After one (1) hour
of nursing
interventions,
goal was partially
met as evidenced
by:
Subjective:
Naintindihan ko,
lagi ko na
gagawin ang mga
yan.
Objective:
*Oral care was
done to patient by
mother as seen in
ward.
*Patient
consumes a total
of 6 oz. during
shifr.
LTG:
After one (1)
month of nursing
interventions,
goal was
successfully met
as evidenced by:

*Patient eats
regularly and
consumes food
fully.
NURSING CARE PLAN FOR READINESS FOR ENHANCED KNOWLEDGE: PREVENTION OF REOCCURRENCE OF ULCERS

ASSESSMENT
Subjective:
Maam, ano po
yung mga
kailangan ko
gawin para
hindi na ito
lumala pa o
magkaroon
ulit?-as
verbalized by
mother
Objective:
*Curious
*Activily ask
queries about
the disease

DIAGNOSIS
Readiness for enhanced
knowledge: Prevention of
reoccurence of ulcers r/t
erythamous lesions
secondary to Apthous
ulcers.
Definition: The presence
or acquisition of
cognitive information
related to a specific topic
is sufficient for meeting
health-related goals and
can be strengthened.

Background Theory:
According to Nola J
Pender, Health promotion
is directed at increasing a
clients level of well
being. The health
promotion model
describes the multi
dimensional nature of
persons as they interact
within their environment
to pursue health.
Therefore nursing actions
must focus on health
promotion

PLANNING
STG:
At the end one (1) hour
nursing interventions,
patients mother will be able
to:
*Verbalize understanding of
health teachings
LTG:
At the end of one (1) month
nursing interventions, patient
will be able to:
*Demonstrate lifestyle
changes that prevents
reoccurrence of apthous
ulcer to child.

NURSING CARE PLAN FOR ACUTE INTERMITTENT PAIN

NURSING INTERVENTION
Independent:
1) Establish rapport.
R: To gain cooperation and trust.
2) Provided health teachings to mother:
>Nutrition: ~Instructed to avoid eating
spicy and hot foods. R: This may lead to
aggreviating the ulcer further.
~Instructed to eat foods that are soft, but
rich in vitamins and minerals. R: Soft
foods will be easy to eat thus not
touching the wounds and will not
provide more aggreviation to the ulcer.
>Fluids: ~Instructed to avoid intake of hot
fluids. R: Hot fluids will cause more pain
to the ulcer.
>Environment: ~Assisted in cleaning the
room and provided adequate ventillation.
>Hygienic Care: ~Demonstrated proper
handwashing technique. ~Instructed to do
daily bath
~Assisted to do oral care to patient.
3)Provided health teachings to mother on how
to acquire apthous ulcer.
R: To avoid triggers.

EVALUATION
STG:
After one (1) hour
of nursing
interventions,
goal was partially
met as evidenced
by:
Subjective:
Salamat,
naiitindihan ko,
alam ko na
ngayon kung ano
mga dapat
iwasan.
Objective:
*Oral care done
as seen in ward.
*Proper
handwashing
technique done as
seen in the ward.

ASSESSMENT
Subjective:
Sakit mama
(while pointing to
mouth)

DIAGNOSIS

PLANNING

NURSING INTERVENTION

Acute intermittent
moderate pain r/t
presence of ulcers around
mouth

STG: At the end of eight (8)


hours nursing intervention,
client will be able to:

Independent:
*Provide bedside care.
R: Bedside care helps in making the environment
clean and pleasing to the eyes & feeling of the
patient, thereby decreasing pain and promoting
comfort.

Definition: Unpleasant

*Pain Scale: 6/10


*Quality:Throbbin
g
*Frequency: Intermittent -as per

sensory & emotional


experience rising from
actual or potential tissue
damage.

mothers
description

According to Virginia
Henderson, It is one of
the 14 needs of the client
is to be free from pain
and be safe at all times.

Objective:
*With
erythmatous
wounds aroung
mouth
*Crying
*Frowning
*Pointing to
ulcers

*Manifest a decrease in pain


*Demonstrate use of relaxation
techniques & other diversional
activities.

Background Theory:

NURSING CARE PLAN FOR RISK FOR INFECTION

* Provide diversional activities such as playing


and listening to music.
R: Diversional activities and relaxation techniques
provides a refreshing feeling and effective way of
diverting clients attention to pain independently.
*Instruct client to avoid moving as much as
possible if unnecessary.
R: Moving frequently that is unnecessary will
cause pain to the patient.
Dependent:
*Administer pain reliver as prescribed.
R: Prescribed pain relivers aids in alleviating the
pain of the patient.

EVALUATION
STG:
After one (1) hour
of nursing
interventions,
goal was partially
met as evidenced
by:
*Patient slept.

ASSESSMENT
Subjective:
Ang dami ng
sugat niya sa
bibig as
verbalized by
the mother
Objective:
*Erythmatous
wounds
around
the mouth
*Disruption of
skin surface on
mouth
*Destruction of
skin layer
bother
epidermis and
dermis

DIAGNOSIS
Risk for infection r/t
damage of primary line
of defense: skin
Definition: At
increased risk for being
invaded by pathogenic
microorganisms.
Background Theory:
According to Florence
Nightingale the
environmental
sanitation and proper
hygiene plays a vital
role in a patients
healing process, with
this, nursing care must
focus on manipulating
the environmental
sanitation and
improving or
enhancing patients
hygiene.

PLANNING
STG: At the end of one
(1) hour nursing
intervention, client will
be able to:

NURSING INTERVENTION
Independent:
1) Establish rapport.
R: To gain cooperation and trust
2) Keep area clean, dry, carefully dress
wounds.
R: Pathogenic Microogranisms thrive in
moist environment.

*Verbalize
understanding of
individual
3) Provide bedside care.
causative/risk factors to R: Bedside care helps in making the
environment clean and conducive to healing
infection.
*Identify interventions
to prevent risk of
infection
*Maintain normal vital
signs.

process thereby preventing acquisition of


pathogenic microorganisms that causes
infection.

4) Provide wound dressing


R: Wound dressing will keep the ulcer free
from infection.
5)Provided health teachings to mother:
>Nutrition: ~Instructed to avoid eating
spicy and hot foods. R: This may lead to
aggreviating the ulcer further.
~Instructed to eat foods that are soft, but
rich in vitamins and minerals. R: Soft
foods will be easy to eat thus not
touching the wounds and will not
provide more aggreviation to the ulcer.
>Fluids: ~Instructed to avoid intake of hot
fluids. R: Hot fluids will cause more pain
to the ulcer.
Dependent:
6) Administer antibiotics as prescribed.
R: Antibiotics prevents development of
infection
7) Monitor and regulate IVF.
R: To maintain adequate hydration.

EVALUATION
STG:
After one (1) hour of
nursing interventions, goal
was partially met as
evidenced by:
*(-) to complications.
*Afebrile
LTG:
After one (1) month of
nursing interventions, goal
was successfully met as
evidenced by:
*Erythmatous wounds are
healed
*No further ulcers were
developed.

Collaborative:
7) Refer to nutritionist and dietician on
appropriate foods and what to avoid.
R: To have proper food and fluid intake.

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