VERAZON, JAYLORD B.

BSN 3A

ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION EVALUATION

EXPLANATION/
PATHOPHYSIOLOGY
Subjective Data: "Risk for impaired Decrease muscle strength PLANNING 1. Assess patient's ability After 8 hours of nursing
“Hindi ko skin integrity to move (shift weight while interventions the patient:
magalaw ang related to hemiparesis" Short term objective: sitting, turn over in bed, 1. Is able to identify
aking kalahating katawan,” Body weakness Within 8 hours of nursing move from bed to chair). individual risk factors.
as interventions the patient Rationale: Immobility is 2. Verbalized
verbalized by the will: the greatest risk factor in understanding of treatment
patient. Irritability -Identify individual risk skin breakdown. needs.
factors. 2. Clean, dry, and 3. Participated to level of
Objective Data: -Verbalize understanding moisturize skin, especially ability to prevent skin
Weak (side of the body) Physical immobility of treatment needs. over bony prominences, breakdown
Immobile (physical -Participate to level of twice daily or as indicated
immobility) needing ability to prevent skin by incontinence or
assistance Risk for impaired skin breakdown. sweating. If powder is
integrity desirable, use medical-
Long term objective: grade cornstarch; avoid
After 2days of nursing talc.
intervention the patient Rationale: To reduce
will: friction.
-Able to demonstrate 3. Assess patient's
behavior/techniques to nutritional status, including
prevent skin breakdown weight, weight loss, and
and serum albumin levels.
-exhibit signs Rationale: An albumin
of bedsores. level greater than 2.5 g/100
ml is a grave sign,
indicating severe protein
depletion.
4. Elevate lower
extremities periodically, if
tolerated.
VERAZON, JAYLORD B. BSN 3A

Rationale: Enhances
venous return. Reduces
edema formation.
5. Reposition frequently,
whether in bed or in sitting
position. Place in prone
position periodically.
Rationale: Improves skin
circulation and reduces
pressure time on bony
prominences.

6. Keep bedclothes dry and

free of wrinkles, crumbs.
Rationale: Reduces/
prevents skin irritation.
7. Emphasize the
importance of adequate
nutritional/fluid intake
Rationale: To maintain
general good health and
skin turgor.
8. Reinforce the
importance of turning,
mobility, and ambulation.
Rationale: These will
enhance their sense of
efficacy and can improve
compliance with the
prescribed interventions.