Nursing Nursing Diagnosis Nursing Planning Intervention Rationales Evaluation

Assessment
1. Determined depth of damage to  To determine the extent of
Subjective P- Impaired Skin Integrity STG: STG:
integumentary system damage.
Cues After 6-8 hrs of 2. Inspected surrounding for erythema, After 8 hrs of nursing
E- related to delayed nursing interventions,  To be able to obtain data. interventions patient:
induration, and maceration.
”Makati at wound healing secondary the client will: 3. Kept the area clean and dry, carefully dress
 To prevent infection. - reduced risk of further
 To reduce risk of infection. impairment of skin
namamaga to impaired circulation, to  Have reduced risk of wounds. integrity as evidenced
 To avoid dehydration
by no actual additional
ang infection, or to
further 4. Encouraged to avoid touching the affected  To avoid further complication tissue breakdown &
impairment of skin part. 
kaliwang 5. Encouraged to increase intake of fluids.
To provide positive nitrogen no persistent reddened
malnutrition. integrity balance to aid in healing and to areas
paa ko.”as  Patient’s caregivers
6. Instructed to avoid foods that trigger maintain general good health. -Patient’s caregivers
S- evidenced by: itchiness. demonstrated
verbalized will demonstrate  To reduce risk of infection, for
understanding& skill in
 Disruption of skin 7. Provided nutrition and increased protein faster healing and to lessen
by the understanding & skill in intake care of wound as
surface itchiness. evidenced by checking
patient. care of wound 8. Administered antibacterial and antipruritic  To assist with developing plan care wound sites
 With dry scales drug as ordered by the physician. for problematic or potentially frequently & cleansing
 Redness @ L Leg 9. Consulted with wound specialist as the wound aseptically.
serious wounds. PARTIALLY
 (+) swelling indicated. MET
 Dry scales

1. Assisted the client and SO(s) in

Delayed wound healing LTG:  Enhancing commitment to plan, LTG:
Objective understanding and following medical After 4 days of nursing
After 3-4 days of nursing regimen and developing program of optimizing outcomes.
Cues interventions the client:
Malnutrition interventions, the client will: preventive care and daily maintenance.  To prevent further complication. - Experienced
 Redness  Experience healing of 2. Inspected skin daily basis, describing  Promotes circulation and reduces healing of wound and
risks associated with immobility. regain skin integrity
@ L Leg Decreased blood circulation wound/regain lesions and changes.
 To promote wound healing (reduced size of wound)
3. Encouraged early ambulation or
 (+) skin
mobilization. on clients who do not have
-Reduced risk of infection
swelling Wound not relived integrity adequate calories.
4. Ensured adequate dietary intake. Review PARTIALLY MET
(reduce size  Provide oral
 Dry Microthrombi
of wound)
dietician’s recommendations
supplementations, tube-
formation 5. Supplemented the diet with vitamins &
scales minerals. Vitamins C and zinc are
feedings or
hyperalimentation to achieve
 Fissures occlusion
 Reduce risk commonly prescribed.
positive nitrogen balance.
in capillaries for infection 6. Administered antibacterial and
 To promote faster healing &
& blood flow antipruritic drug as ordered by the
reduce infection tissue
physician.
 To enhance healing, reduce rick of
 Redness @ L Leg 7. Referred to dietitian or certified educator
recurrence of diabetic ulcers.
as appropriate.
 (+) swelling
 Dry scales
 Fissures
Sasi, Karen Pursha O. BSN-19 GRP. 74A