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Monta NCP

1. The patient has an impaired skin integrity due to a stroke evidenced by a pressure ulcer on the sacral area. 2. Within 4 hours of nursing interventions, the goal is for the patient to participate in decreasing friction on the existing pressure ulcer by turning hourly, maintaining an empty stomach, and monitoring vital signs. 3. Evaluation after 4 hours found the goal was met as the patient could participate in the interventions to decrease friction on the pressure ulcer.

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ROGEN KATE AZARCON
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47 views2 pages

Monta NCP

1. The patient has an impaired skin integrity due to a stroke evidenced by a pressure ulcer on the sacral area. 2. Within 4 hours of nursing interventions, the goal is for the patient to participate in decreasing friction on the existing pressure ulcer by turning hourly, maintaining an empty stomach, and monitoring vital signs. 3. Evaluation after 4 hours found the goal was met as the patient could participate in the interventions to decrease friction on the pressure ulcer.

Uploaded by

ROGEN KATE AZARCON
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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FATHER SATURNINO URIOS UNIVERSITY

San Francisco St. Butuan City 8600, Region XIII Caraga, Philippines

Nursing Program
Name: Rizza Aubrey Miles Monta
Date: March 6, 2023

NURSING CARE PLAN

Assessment Nursing Planning Nursing Intervention Rationale Evaluation


Diagnosis

Impaired skin Within 4 hours of Independent: After 4 hours of


Subjective Cues: integrity related nursing interventions , 1. to monitor any alterations of the patient nursing
No statement to Stroke as the patient will be able 1. monitor vitals signs of interventions , the
2. to monitor signs of dehydration of
verbalized by the evidenced by to: patient was able
patient
patient Pressure ulcer Participate in the patient to:
at Sacral area interventions provided 2. measure and record
3. proper placing of tubes prevent from
by the student nurse in Participate in the
and input and output of
order to decrease any infections and pain of the patient interventions
Objective Cues: friction of the existing patient provided by the
4. since it is prescribed by the doctor to
pressure ulcer student nurse in
-slurred speech 3. assess the placement
maintain NPO today because the patient order to decrease
noted of the tubes attached to friction of the
will undergo minor operation
existing pressure
-limited ROM the patient such as NGT
5. this is to determine the score of the ulcer
noted tube and FBC
patient with stroke using Glascow Comma
Goal Met
- Pressure ulcer at 4. instruct watcher of
Scale
the sacral area patient to maintain the
6. to prevent shearing of the skin of the
R.A.M.Monta ,
- With NGT at left patient in empty stomach
patient and decrease spreading of FSUU/SN
nostril and FBC to or do not feed anything
urobag pressure ulcer
(NPO)
7. to maintain hygiene of the patient and
- CRT >2 seconds 5. check and assess the
GCS of patient facilitate decreasing of Bp of the patient
6. Turn the patient side to 8. to check for signs of fluid loss in the
Initial V/S: side hourly and make sure body of patient
to the patient lying flat on 9. This information can assist the patient
bed or caregiver in finding methods to prevent
T- 36.2
7. instructed watcher to do skin breakdown.
P- 76 TSB to the patient 10. The WOCN can assist staff, patient,
R- 18 8. check skin turgor and family in product selection, education,
9. Educate patient and and development of a prevention plan.
Bp- 130/90
caregiver about the
O2 - 97% causes of pressure.
10. Communicate with a
wound, ostomy, and
continence nurse
(WOCN).

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