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ASSESSMENT

NURSING DIAGNOSIS

SCIENTIFIC RATIONALE

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION

O> altered level of consciousness >generalized weakness >numbness of the lower extremities >disruption of skin layers at the left leg >edema on both upper and lower extremities >muscle weakness >diagnosed DM patient

Impaired skin integrity r/t large vessel destruction as evidenced by alteration in pressure distribution, ulceration

Alterations in blood flow / blood viscosity, increased platelet aggregation, and accelerated capillary endothelial growth / large vessel destruction / loss of foot sensation / completely unnoticed cuts or trauma to the skin / blood glucose concentration may slow or even reverse this pathological process / Slow wound healing process

D.O. After 1 wk of nursing interventions, the patient will be able to display improvement in wound healing as evidenced by: Intact skin and Minimized presence of wound. Absence of itchiness, redness S.T.O. After 8 hours of nursing intervention the patient will be able to: Participate in prevention measures and treatment program Demonstrate proper wound care c/o watcher

INDEPENDENT Assessed skin. Noted color, turgor, and sensation. Described wounds and observed changes. Demonstrated good skin hygiene, e.g., wash thoroughly and pat dry carefully. Establishes comparative baseline providing opportunity for timely intervention. (Doenges) Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin. (Brunner) Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for infection. (Kozier) Improved nutrition and hydration will improved skin condition. (Doenges) Assists them in optimal healing with less expensive resources. (taylor) Long and rough nails increases risk of skin

D.O. At the end of the 1 week nursing intervention, the client was able to display improvement in wound healing as evidenced by: Intact skin Minimized presence of wounds, Absence of redness or itchiness S.T.O. After 8 hours of nursing intervention the patient will be able to: Participate in prevention measures and treatment program Demonstrate proper wound care c/o watcher

Instructed family to maintain clean, dry clothes preferably cotton fabric

Emphasize importance of adequate nutrition and fluid intake. Demonstrate to family members how to make a guava decoction to apply in the wound as alternative disinfectant.

Instruct the family to clip and file the nails regularly.

damage. (Kozier) .

Provided and applied wound dressings carefully. Apply lotion on legs COLLABORATIVE Note laboratory results pertinent to causative factors (Hb/Hct, blood glucose, albumin) Assist with debridement therapy as indicated.

Wound dressings protect the wound and the surrounding tissues. (Doenges) To prevent dryness of skin (Kozier)

To assess causative factors. (Kozier)

To clean the wounded area and prevents contamination. (Brunner)