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ASSESSMENT NURSING

DIAGNOSIS

PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective cues:May sugat ako sa

tiyan kasi sinaksakako as verbalized

by the patient.

Objective cues:>Disruption of skinsurface at

abdominal area

>Wound with cleansurgical dressing

>Vital signs are asfollows:

BP: 110/80PR: 78

RR: 18

Temperature: 36.7C

Impaired skin

integrity related to

trauma: injury dueto stabbed wound

Short-term goal:

After 8 hours ofnursing

interventions, theclient will be able to

prevent infection,

and maintain skinintegrity.

Long-term goal:

After 3 days of

nursinginterventions, the

client will displaytimely healing of

the wound without

complication.

Independent:>Assess site of skin

impairment anddetermine etiology.

>Determine degree

and depth of injury.

>Monitor site of

skin impairment atleast once a day for

color changes,redness, swelling,

warmth, pain, or

other signs ofinfection. Determine

whether client is

experiencingchanges in sensation

or pain.

>Emphasizeimportance of

adequate nutrition

and fluid intake.

Prior assessment of

wound etiology iscritical for proper

identification ofnursing

interventions.

For proper

identification ofnursing

interventions.

To monitor for

changes and earlysigns of infection.

Inadequatenutritional intake

compromises

healing.

After 8 hours ofnursing

interventions, thegoal was met as

evidenced by (-)

signs of infectionand stable vital

signs.

After 3 days of

nursinginterventions, the

goal was met asevidenced by timely

wound healing,

without any furthercomplications.

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>Perform wound

care on a regular

basis, as indicated.

>Carefully dresswound, and prevent

infection.

>Apply appropriate

dressing.

Dependent:

>Administerprescribed

medications, such asascorbic acid.

>Provide optimum

nutrition, including

vitamins andincreased protein

intake, as indicated.

Collaborative:>Review laboratory

data.

To maintain skin

integrity and

prevent infection.

To assist bodysnatural process of

repair.

For wound healing.

Vitamin C promoteswound healing.

To provide a

positive nitrogen

balance to aid inskin and tissue

healing and tomaintain general

good health.

>To gather baseline

data and identifychanges.