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Short Term: Independent:: Tuberculoid Leprosy

1. The patient has a chronic ulcer on the right sole due to tuberculoid leprosy, as evidenced by enlarged nerves in the toes and sensation alteration. 2. The nursing diagnoses are risk for impaired tissue integrity related to sensation alteration from leprosy and risk for infection. 3. The plan is to provide wound cleansing, apply sterile dressings, encourage vitamin/nutrition intake, and apply topical antimicrobial as ordered to heal the ulcer over 7-10 months.

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Kevin Dare
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377 views3 pages

Short Term: Independent:: Tuberculoid Leprosy

1. The patient has a chronic ulcer on the right sole due to tuberculoid leprosy, as evidenced by enlarged nerves in the toes and sensation alteration. 2. The nursing diagnoses are risk for impaired tissue integrity related to sensation alteration from leprosy and risk for infection. 3. The plan is to provide wound cleansing, apply sterile dressings, encourage vitamin/nutrition intake, and apply topical antimicrobial as ordered to heal the ulcer over 7-10 months.

Uploaded by

Kevin Dare
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Assessment Analysis/ Nursing Diagnosis Planning Implementation Evaluation

Subjective Data:  Decrease sensory Short Term: Independent: -Px experience normal skin tissue
 “matagal na yung perception related -In 20-30 mins, the -Assess patient's sensation
sugat” as to sensation patient will have a numbness and relief
verbalized by alteration relief from -Px maintains adequate nutritional
patient referring to secondary to numbness after -Provide compression intake as evidenced of being relief
ulcer leprosy taking up Niacin therapy service from pressure ulcer
 “kahit hawakan (vit B) as ordered
walang by the physician -Perform leg elevation -Px maintains activity level within
pakiramdam” or capabilities as evidenced of being
numbness -Asses patient's pain free of pressure ulcer
 “mahirap and relief
makalakad”
-Cleansing of the leg
Long Term: ulcer with warmed tap
Objective Data: -After 4-6 months water or saline is usually
 Edema on right of medication by sufficient
foot applying PHMB
 Pus in ulcer on the antimicrobial to the -Provide clean and
right foot ulcer as ordered by simple dressing
the physician, the technique using a
ulceration is dry stocking or bandage
and healed
Dependent:
-Topical administration
of Polyhexanide
(Lavasept) as ordered to
fasten healing

-Health teaching about


Self-medication of
prescribed antibiotics by
physician.
Actual Problem: Tuberculoid Leprosy
Risk for:

Assessment Analysis/ Nursing Planning Nursing Care Plan/ Evaluation


Diagnosis Implementation
Subjective Data:  Risk for Short Term: Independent: -Px experience normal skin
 The patient states impaired tissue -In 20-30 mins, the patient tissue sensation
that the lesions are integrity r/t will have a relief from - assess for
“madalas mainit” sensation numbness after taking up superinfection -Px maintains adequate
as verbalized by alteration Niacin (vit B) as ordered by and nutritional intake as
patient secondary to the physician evidenced of being relief
 Occasional leprosy - will clean the from pressure ulcer
numbness wounds with saline
 Muscle weakness or nontoxic -Px maintains activity level
 “mahirap substances as within capabilities as
maglakad” indicated evidenced of being free of
 Immobility Long Term: pressure ulcer
-After 7-10 months of - Apply
medication by applying sterile bandage to
PHMB antimicrobial to the cover the wounds
Objective Data: ulcer as ordered by the and maintain
 Enlarged nerves in physician, the ulceration is aseptic technique.
the toes dry and healed
 Chronic ulcers on -encourage patient
the right sole of to increase
the feet vitamins C intake
to fasten healing of
wounds

Dependent:

-Encourage to ma-
intain regular med-
ical by applying
Polyhexanide
(Lavasept)
antimicrobial as
ordered by
physician

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