Tissue Integrity Nursing Care Plans (NCP)

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					RLE FORM 002

                                                                                      Cebu Normal University
                                                                                        College of Nursing
                                                                                            Cebu City

                                                                Mission-Vision: Care Using Knowledge and Compassion

                                                                                       NURSING CARE PLAN

 NCP Scoring                      10 pts                             Defining Characteristics                                 3 pts                  Intervention                             3 pts
 Nursing Diagnosis                2 pts                              Outcome                                                  1 pt                   Bibliography       1 pt at least 5 references

Client Name: _N.L.P._____________________________________________________                                    Patient Care Classification: (Please Check)
Age: _21_ Sex: M_ Civil Status: _Single______ Religion: _Roman Catholic__________                            ___________ Wholly Compensatory: Pts. therapeutic self-care is accomplished by
Allergies: Food: No Food Allergies                                                        _                                  nurse
           Drug: No Drug Allergies                                                        _                  ___________ Partially Compensatory: Pts. performs some self-care measures
Diet: Diet as Tolerated (DAT)                                                             _                  __________ Supportive Educative: Pts. accomplishes self-care measures
Date of Admission: November 12, 2009; 10:02 PM                                            _                  Clinical Division and Bed No: Ward VIII; Bed no. X-3                                 _
Diagnosis: Osteomyelitis Tibia at Left Leg; Status post Application of Illizarove Fixator _                  Name of Physician: Dr. Kristia Jimmylou Akiatan                                      _
______________________________________________________________________                                       Name of Student: Herbert Almendras Huyo                                              _

                                                     EXPECTEED OUTCOME CRITERIA                                                                           BEHAVIORAL OUTCOME
    DEFINING CHARACTERISTICS                                                                          INTERVENTION AND RATIONALE
                                                                (Ideal)                                                                                         (Actual)
 Nursing Diagnosis:                                  SHORT TERM GOAL:                               Independent:
 Impaired    Tissue   Integrity     related  to       Within 8 hours of nursing interventions,          I > Inspect the wound for color, texture,
 pathological interruption of       the tissue        client will be able to demonstrate behaviors            turgor and presence of discharges
 secondary to disease process                         or lifestyle changes to promote healing and        R > to assess extent of involvement
                                                      prevent further complications.                              (Doenges, et. al., p. 489)
 S: “Nalungag na ni akong tiil kay nigawas                                                              I > Inspect wounds daily for changes
   man ang nana” as verbalized
                                                                                                         R > promote timely revision of plan
 O:> received sitting on bed awake, coherent         LONG TERM GOAL:                                            (Doenges, et. al., p. 563)
   > swelling around the noted                        Within 6 days of nursing interventions,
   > redness around the area observed                 client will be able to display progressive        I > Promote early mobilization
   > pus discharges noted                             improvement in wound healing.                      R > to promote circulation
   > limited range of motion observed                                                                             (Doenges, et. al., p. 563)
   > dressing covered with elastic
     bandage at the left tibial area

                                                                                                                                                           HERBERT ALMENDRAS HUYO
                                                    EXPECTEED OUTCOME CRITERIA                                                                                 BEHAVIORAL OUTCOME
   DEFINING CHARACTERISTICS                                                                             INTERVENTION AND RATIONALE
                                                               (Ideal)                                                                                               (Actual)
No Significant Laboratory Findings                                                                        I > Support affected body parts using             I > Keep side rails in raise position to
                                                                                                               pillows                                            aid client mobility
                                                                                                           R > to maintain proper body alignment and          R > helps weak client turn independently
                                                                                                               increase comfort                                   and ensure client’s safety
                                                                                                                    (Craven & Hirnle, p. 784)                         (Craven & Hirnle, p. 784)

                                                                                                          I > Schedule activities with adequate rest        I > Encourage adequate intake of fluids
                                                                                                               periods during the day                             and nutritious foods such as those
                                                                                                           R > to conserve energy and to prevent                  rich in carbohydrates and protein
                                                                                                               fatigue                                        R > promotes well-being and maximizes
                                                                                                                    (Doenges, et. al., p. 354)                    energy production
                                                                                                                                                                      (Doenges, et. al., p. 355)
                                                                                                          I > Turning      schedules    should   be
Theoretical Basis:                                                                                             Incorporated in the plan of care and
                                                                                                               posted at the bedside if the client is
     Impaired Physical mobility is a state in          As the infection extends through the cortex
                                                                                                               receiving care in the home, a long
which the person experiences a limitation in       of the bone, it involves the periosteum and the
                                                                                                               term facility or hospital
independent, purposeful physical movement          soft tissues. The infected area becomes
                                                                                                           R > helps ensure consistency of care
of the body or one or more extremities             painful, swollen, and extremely tender. The
                                                                                                               between different shifts and different
(NANDA, 2005).                                     patient may describe a constant, pulsating pain
     The musculoskeletal system is the             that intensifies with movement as a result of the
                                                                                                                    (Craven & Hirnle, p. 783)
supporting framework for the body thus it          pressure of the collecting pus thus it limit
involved in movement and is responsible for        movements (Smeltzer & Bare, 2004).
the body’s form and shape. Central and                                                                 Dependent / Collaborative
peripheral nerves coordinate movement’s                                                                   I > Administer analgesics as indicated
complex activity. Maintaining balance and                                                                       prior to activity
posture against the force of gravity requires                                                              R > to divert and alleviate pain and also to
smooth coordination of muscles, joints, and                                                                    permit maximal effort in activity
nerves and a stable center of gravity (Martini,                                                                      (Doenges, et. al., p. 390)
et. al., 2001).
     In impaired mobility, it is often caused by                                                          I > Consult with physical/occupational
or accompanied by pain on movement. Pain                                                                        therapist as indicated
can result from physical injury, as in sprains,                                                            R > to develop individual exercise
strains or torn ligaments, or it may result from                                                                    (Doenges, et. al., p. 355)
degenerative and inflammatory processes
(Craven & Hirnle, 2003).

                                                                                                                                                                HERBERT ALMENDRAS HUYO

Description: Tissue Integrity Nursing Care Plans (NCP); nursing care plan, nursing diagnosis, care plan, nursing care plans, nursing care, pain control, care plans, nursing interventions, nursing home, acute care, nursing homes