NURSING CARE PLAN #3 DAT E& SHIF T ASSESSMENT NURSING DIAGNOSIS NEED S PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: May mga sugat ako. as verbalized by thepatient. Objective: Disruption of skinsurface at the lower extremity. Wound is 5mm indiameter. Localized erythema Purulent discharge (+) pruritus on thesite of the wound.

Impaired skinintegrity related toinflammatoryresp onse secondaryto infection

SCIENTIFIC BASIS:

Following a 3daynursing intervention,the client will be ableto display improvementin wound healing asevidenced by: Intact skin or minimizedprese nce of wound. Wound is less than5mm in diameter. Absence of rednessor erythema. Absence of purulent discharge. Absence of itchiness.

Assessed skin.Noted color, turgor,and sensation.Describe d andmeasured woundsand observedchanges. Demonstrated goodskin hygiene, e.g.,wash thoroughlyand pat drycarefully. Instructed family tomaintain clean, dryclothes, preferablycotton fabric (any T-shirt) Emphasizedimporta nce of adequate nutritionand fluid intake. Demonstrated tothe family

. Establishescomparativebas eline providingopportunity for timely intervention. Maintaining clean,dry skin provides abarrier to infection.Patting skin dryinstead of rubbingreduces risk of dermal trauma tofragile skin. Skin friction causedby stiff or roughclothes leads toirritation of fragileskin and increasesrisk for infection. Improved nutritionand hydration willimprove skincondition. Providing the familywith alternativesolution assiststhem in optimalhealing with lessexpensiveresources.

At the end of the 3-daynursing intervention,the client was able todisplay improvement inwound healing asevidenced by: Minimized presenceof wounds. Several woundshave dried up. Minimizederythe ma. Minimized purulentdischarg e. Wounds are still atleast 5mm indiameter. (Continuecleanin

memberson how to make aguava decoction toapply to the woundas alternativedisinfect ant. Instructed family toclip and file nailsregularly. Provided andapplied wounddressings carefully

Long and roughnails increase riskof skin damage. Wound dressingsprotect the woundand thesurroundingtissues.

g the woundwith disinfectant) Presence of itchiness. (Continue> instructing client toavoid scratching thewound