ASSESSMENT DIGANOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective: Impaired skin At the end of Goal met

integrity r/t the shift, the  Change Moisture causes
 Presence alteration in patient will diaper skin breakdown The patient
of rashes skin be able to provide was able to
under the appearance as prevent perineal prevent further
right breast manifested by further skin care as skin
and both presence of breakdown needed, breakdown
inguinal rashes and keep
area the areas
clean and
 Disruption dry
of skin
surface
 Place soft
gauze
under the
breast and
axillary,
and tissue
on the
inguinal
area

 Avoid To prevent with

wrinkles at skin irritation
the linens

 Avoid use
of tight
clothes or
diaper

 Reposition To promote
the patient blood flow and
every 3 reduce duration
hours and magnitude
of pressure on
 Use the skin
Dermacyn
Spray to
clean the
area and
 apply thin
layer of
Fucicort
Cream as
ordered

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objectives: Risk for fall r/t Within 4 to 5  Identify To know the Goal met
to impaired hours of factors that intervention
 Decrease physical rendering affect safety that will be Within 4 to 5 hours
strength in mobility proper needs established of rendering
all nursing proper nursing
extremities intervention,  Assess Proper intervention the
the patient conditions assessment patient is free from
 Weakness will be free that can helps fall
from fall increase the determine
 Immobility patient’s level needed fall For continuous
of fall risk, precautions monitoring
such as a
history of
falls, changes
in mental
status,
sensory
deficits,
balance,
medications,
and
symptoms
related to
diseases

 Always stay
with the To prevent
patient if the patient
side rails are falling from
down bed
 Always hold
the patient
properly
during turning
positions
 Always put
the side rails
up before
leaving the
patient
 Keep the bed
at the lowest
position