NURSING CARE PLAN
PLANNING
ASSESSMENT NURSING OBJECTIVE INTERVENTION RATIONALE IMPLEMENTATION EVALUATION
DIAGNOSIS OF CARE
Subjective After 1 week 1. Provide 1. To promote 1. Implemented wound After rendering
cues: Risk for of nursing wound care with healing, prevent care procedures, the appropriate
Infection interventions, aseptic technique. infection, and including cleansing, nursing
-Patient related to the patient maintain a clean dressing changes, and interventions to
verbalized open will be able and sterile wound wound protection, to the patient, the
presence of fracture to: environment. promote healing and goal of care was
pain and prevent infection. met.
discomfort at 1. Maintai
the site of n a clean 2. Conducted 1. Maintaine
the open and sterile 2. Educate on the 2. To empower and educational sessions to d a clean and
fracture, wound importance of encourage the provide information on sterile wound
rating his environment proper wound care patient to proper wound care environment.
pain level at to minimize techniques. effectively care for techniques, emphasizing Patient’s wound
6/10. the risk of their wound and the importance of was cleaned
infection. prevent cleanliness and infection and dressed
Objective complications. prevention. using sterile
cues: techniques.
3. Showed the patient
- Open wound 3. Demonstrate how to cleanse the 2. The patient
at the site of proper wound 3. To ensure the wound using sterile adhered to the
the fracture. cleansing patient solutions and supplies, prescribed
techniques using understands and ensuring they antibiotic
Vital sterile solutions and can perform the understood the proper regimen. Patient
supplies. necessary steps to techniques for consistently
signs: T- maintain a clean maintaining a clean followed the
wound wound environment. physician’s
37.5°C environment and instructions
P- 83 bpm reduce the risk of regarding the
R- 17 infection. 4. Provided instructions antibiotics.
bpm BP- 4. Instruct the on the recommended
130/80 patient on the 4. To promote frequency of dressing 3. The patient
mmhg appropriate proper wound changes and enumerated the
O2SAT- frequency of healing, prevent demonstrated the different signs
97% dressing changes contamination, and proper application of and symptoms
and how to properly maintain a sterile sterile dressings to of infection,
apply sterile environment. maintain a sterile such as
dressings.
NURSING CARE PLAN
wound environment. increased
redness,
swelling, pain,
and drainage.
No signs
of infection
2. Adhere to 5. Support 5. To ensure the 5. Offered support and reported. Pain
the medication patient takes the guidance to the level at 2/10.
prescribed adherence. prescribed patient to ensure they Patient was
antibiotic antibiotics as followed the proactive in
regimen to directed, prescribed antibiotic communicating
prevent or preventing or regimen as directed, any changes or
treat treating infection including reminders concerns related
infection. effectively. and encouragement. to the wound.
6. Clearly explain the 6. Clearly communicated
prescribed antibiotic 6. To ensure the the details of the
regimen, including patient prescribed antibiotic
the purpose, correct understands the regimen, including the
dose, frequency, and importance of correct dose, frequency,
duration. following the and duration, to ensure
prescribed the patient understood
antibiotic regimen how to take the
accurately for medication properly.
optimal infection
prevention or
7. Provide written treatment. 7. Offered written
instructions and a instructions and a
medication schedule 7. To assist the medication schedule to
to help the patient patient in adhering the patient, providing a
remember when to to the prescribed tangible reminder and
take their antibiotic regimen reference to help them
antibiotics. and minimize the adhere to the
risk of missed prescribed antibiotic
3. Report any doses. regimen.
signs or
symptoms of 8. Emphasize 8. Stressed the
infection, if prompt reporting importance of promptly
present, of infection signs 8. To enable early reporting any signs or
such as or symptoms. detection and symptoms of infection,
NURSING CARE PLAN
increased timely
redness, intervention, such as increased
swelling, reducing the risk redness, swelling, pain,
pain, or of complications or drainage from the
drainage, associated with wound, to ensure timely
promptly to infection. intervention.
the
healthcare
provider
9. Educate the 9. To empower the 9. Provided education
patient on the signs patient to on the specific signs
and symptoms of recognize potential and symptoms of
infection, such as infection and seek infection, ensuring
increased redness, appropriate the patient was
swelling, pain, or medical attention aware of the
drainage from the promptly. potential indicators
wound. and could recognize
them if they
10.Encourage the occurred.
patient to promptly 10.To ensure
report any timely assessment 10.Emphasized the
concerning changes and intervention, importance of promptly
or symptoms to the reducing the risk reporting any
healthcare provider. of complications concerning changes or
and promoting symptoms related to
optimal wound the wound or signs of
healing. infection to the
healthcare provider,
ensuring timely
assessment
and intervention.
Reference/s:
Valino R. (n.d.) NCP: Impaired Physical Immobility Related To Loss of A Limb (Amputation). SCRIBD.
Retrieved from: https://www.scribd.com/document/291551301/NCP-docx
NURSING CARE PLAN
Vera M. (2023). 4 Amputation Nursing Care Plans. Nurseslabs. Retrieved from: https://nurseslabs.com/amputation-
nursing-care- plans/
Wayne G. (2024). Physical Mobility & Immobility Nursing Care Plan and Management. Nurseslabs.
Retrieved from: https://nurseslabs.com/impaired-physical-mobility/
