Date/ Cues Need Nursing Patient Nursing Intervention Implementation Evaluation

Time Diagnosis Outcome

January Subjective:
26, 2023 @ “Last month 1. Allow the patient to January 26, 2023
10:30 AM man ko nagpa Impaired Tissue After 8 hours assume a position of
Check-up Integrity related of nursing 1 @ 2:30 PM
comfort.
Ma’am kay nag E to secretions as intervention
Goal Partially
bleeding ko. evidenced by the client will
Mao wala ko
L bleeding. be able to: Rationale: To provide Meet
navaccinan ug I comfort in the patient
tetanus toxoid.” M a. Patient
I Rationale: reports
After 8 hours of
“Usahay ma’am Pregnant any altered
sakit siya. N women are prone sensation
2. Administer antibiotics nursing
as ordered. intervention the
Karong adlaw A to several or pain at
client was able
ra sab Nawala T complications if site of Rationale: Although to:
ang bleeding.” I mishandle tissue intravenous antibiotics
properly such as impairment may be indicated, wound
O severe bleeding . infections may be a. Patient
Objective: N that may fall into managed well and more 2
miscarriage or b. Patient efficiently with topical reports that pain
Temp: 36.6 0 C infection. demonstra agents.
BP: 110/60 tes at site of tissue
mmHg understan 3. Check for the patient’s
CR: 86 bpm Vaginal bleeding. ding of Vital signs. impairment has
PR: 86 bpm (n.d.). Vaginal plan to
RR: 21 cpm heal tissue gone “Nawala na
Bleeding | Rationale:
and
Healthdirect. Vitals provides us with an ang sakit ug
prevent assessment of our
Weight: 67.7 kg
https://www.healt injury.
hdirect.gov.au/va general health. They alert bleeding.”
Vaginal us to early indicators of 3
Bleeding within ginal-bleeding
infection, stop a
one month misdiagnosis, find medical
c. Patient’s issues without symptoms, b. Patient
wound and motivate us to make
decreases wiser decisions. demonstrated the
in size and
has 4. Provide tissue care as
plan to heal
increased needed.
granulation tissue and
Rationale: Each type of
tissue. wound is best treated prevent injury.
based on its etiology. Skin
wounds may be covered
with wet or dry dressings,
topical creams or 4
lubricants, hydrocolloid
dressings (e.g.,
DuoDerm), or vapor-
permeable membrane c. Patient’
dressings such as
wound decreases
Tegaderm.
in size and had
5. Keep a sterile
dressing technique increased
during wound care.
granulation
Rationale: A sterile
technique reduces the risk tissue.
of infection in impaired
tissue integrity. This
involves the use of a
sterile procedure field, 5
sterile gloves, sterile
supplies and dressing,
sterile instruments (Kent
et al., 2018).

6. Explain to the patient

about causes of pain
and interventions to 6
take in relieving the
pain.

Rationale: Provides
understanding on the
treatments and
medications.

7. Encourage a diet that

meets nutritional
 needs.
7
Rationale: A high-protein,
high-calorie diet may be
needed to promote
healing.

8. Educate patient about

proper nutrition,
hydration, and
methods to maintain
tissue integrity. 8

Rationale: The patient

needs proper knowledge
of their condition to
prevent impaired tissue
integrity.
 9. Encourage the patient
to do bed rest and
avoid doing heavy
physical activities. 9

Rationale: To avoid
furthermore bleeding that
can lead to some
complications such as
miscarriage and promote
tissue healing

10. Instruct the patient to

continue the
medication prescribed 10
by the doctor.

Rationale: To promote
faster healing & avoid
some complications that
may risk the life of the
baby.

WAYNE, G. (n.d.). Impaired Tissue Integrity & Wound Care Nursing Care Plan. Nurseslabs. Retrieved February 13, 2023, from

https://nurseslabs.com/impaired-tissue-integrity/

Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (n.d.). NURSING DIAGNOSES Definitions and Classification (12th ed.). Thieme Medical

Publishers, Inc.