Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

Subjective: Impaired Skin Following a 3 day  Assessed skin.  Establishes At the end of the 3 day
Integrity related to nursing intervention, Noted color, comparative nursing intervention
‘’ may mga sugat inflammatory response the client will be able turgor, and baseline the client was able to
ako.’’ As verbalized secondary to infection to display sensation. providing display improvement
by the patient. improvement in Described and opportunity in wound healing as
wound healing as measured for timely evidenced by:
Objective: evidenced by: wounds and intervention.
 Disruption of observed  Minimized
the skin  Intact skin or changes.  Maintaining presence of
surface at the minimized clean, dry skin wounds.
both side of presence of  Demonstrated provides a  Several
lower wound. good skin barrier to wounds have
extremity.  Absence of hygiene, e.g, infection. dried up.
 Wound purulent of wash Patting skin  Minimized
 Purulent discharge. thoroughly dry instead of purulent
discharge  Absence of and pat dry rubbing discharge.
 (positive) itchiness. carefully. reduces risk of
pruritus on the dermal trauma  Presence of
site of wound.  Instructed to fragile skin. itchiness
 Positive pain. family to
maintain  Skin friction
clean, dry caused by stiff
clothes, or rough
preferably clothes leads
cotton to irritation of
fabric(any T- fragile skin
shirt). and increases
risk for
infection.
Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation
Fluid Volume Excess SHORT TERM:  Establishes  To assess SHORT TERM:
Objective: R/T decrease After 4-8 hours of rapport precipitating The patient shall have
 Patient Glomerular filtration nursing interventions, and causative demonstrated
manifested: rate and sodium patient will factors. behaviors to monitor
 Edema retention demonstrate behaviors  Monitor and  To obtain fluid status and reduce
 Hypertension to monitor fluid status record vital baseline data. recurrence of fluid
 Weight gain and reduce recurrence signs excess.
 Pulmonary of fluid excess.  Assess  Obtain
congestion(SOB, possible risk baseline data LONG TERM:
DOB) LONG TERM: factors The patient shall have
 Oliguria After 3 days of manifested stabilized
 Distended nursing intervention  Monitor and  To note for fluid volume, AEB
jugular vein. the patient will record vital presence of balance I&O, Normal
manifest stabilize sign nausea and VS, Stable weight and
fluid volume AEB vomiting. free from signs of
balance I&O, normal edema.
VS, Stable weight and  Assess  To prevent
free from signs of patient’s fluid overload
edema. appetite and monitor
intake and
output.
 Note  To monitor
amount/rate of fluid retention
fluid intake and evaluate
from all degree of
sources. excess.