Care Planning Template for Nursing Diagnosis and Interventions

Care Planning Template
Nursing Diagnostic Statement 1
Acute pain (Herdman and kamitsuru,2014) related to stage one pressure injury on her right
ischial tuberosity as evidenced by pain score 7 out of 10, by on questioning Heather stated
that she has pain and she described the pain as “it really hurts if I sit for too long in my
wheelchair due to the community nurse who helped her in bathing, shifting and doing other
routine activities. When she has to wait too long on wheelchair for her home nurse to come
then it causes her great pain because she even cannot shift to bed for her afternoon sleep
without their support.
Expected Outcome 1
The patient shall verbalize relief of pain to a scale of 4/10 by the end of four hours
Nursing Intervention 1
Relieving pressure on the injury area by use of a special pillow, foam cushions or mattress
pads. Water or air filled pads may also be used. Patient position every 15 minutes will also be
practiced
Rationale 1
Relieving pressure will increase blood flow to the pressure area and hence pain relief (Joyner
and Casey, 2015).
Nursing Intervention 2
Wash the pressure area gently with mild soap and water and dry after washing. The area
should never be massaged. Moisture barrier can also be used to prevent fluid on the area.
Rationale 2
This will help enhance comfort and also encourage blood flow around the pressure area hence
relieving pain around the area (Mclnnes, et.al, 2015).
Nursing Intervention 3
Administer analgesics such as non-steroidal anti-inflammatory drugs (NSAIDS) as
prescribed. Paracetamol 1g is helpful in mild pain and opioids can be used for severe pain.
Heather cook will need non opioids such as morphine since her pain is severe (7/10) (Dowell,
Haegerich, & Chou, 2016). Side effects of this drugs should be monitored closely.
Rationale 3
Opioids relief pain by binding to receptors found in brain, spinal cord and other nervous
tissue which are normally activated by enkephalins and endorphin (Nalini, Howar, &
Laxmaiah, 2011). Binding to receptors of the pressure area leads to pain relief.
Nursing Intervention 4
Explain to the client the causes of pain or discomfort and the importance of care of the
pressure area especially during discharge to home. Highlight the importance of taking
prescribed medication as prescribe and at the right time.
Rationale 4

Patient’s knowledge on precipitating factors of pain is helpful as it helps to
control pain (Linton, & Shaw, 2011). Therefore, the patient will avoid
unnecessary pain. This creates cooperation in pain management (Latimer,
Chaboyer, & Gillespie, 2014).

Nursing Diagnostic Statement 2
Risk of infection related to indwelling catheter (Newman, & Willson, 2011), hospitalization
and lowered immunity due to multiple sclerosis
Expected Outcome 2
Heather to remain free from infection and be able to pick out any signs of infections early to
allow for immediate treatment
Nursing Intervention 1
Monitor Heather for any signs of pain, swelling, redness or purulent discharge around the
catheter areas or wounds. Educate the patient concerning this sign and to inform the nurse in
case she notices any.
Rationale 1
Pain, swelling, redness, discharge are the classic signs which indicate presence of infection
(Surrena, 2010). therefore, noticing such signs will be a clear indication of infection.
educating the Patient concerning the signs will also encourage early detection.
Nursing Intervention 2
Assess the skin often for moisture, elasticity, color and texture (Dillon, 2015).
Rationale 2
Skin is the body’s first line of defense against pathogens, therefore assessing it carefully and
in a proper way will help in preventing its breakdown. In case of impaired skin integrity,
pathogens will easily enter into the body through the breaks and hence causing infections.
Nursing Intervention 3
Ensure that sterile technique is strictly observed when the urinary catheter is being changed
and that the catheters are appropriately cared for in every shift.
Rationale 3
Nosocomial infections commonly occur through the genito-urinary tract (Jordan, & Nicolle,
2014).
Nursing Intervention 4
Practice proper hand washing mechanism before and after being in contact with the patient
and her environment and also teach her how to wash hands properly and why she should do
so. Visitors and other health staff should also be encouraged to wash their hands before
handling the patient
Rationale 4
Proper hand washing effectively remove microorganism from the hands (Lynn, 2018). This
therefore greatly lowers the spreading of pathogens form one individual to a patient and also
form one part of the body to another.