Assessment

Subjective
May sugat
po ako
paa.
As verbalized
by the
patient.

Objective:
Wound in
the right foot.

Nursing
Diagnosis
Impaired skin
integrity
related
to
inflammatory
response
secondary to
infection

Planning

Intervention

After 8 hrs of
nursing intervention
the client will be
able to display
improvement i n
wound healing as
evidenced by:

Assessed skin,. Noted

color, turgor and sensation.
Described and measured
wounds and observed
changes.
Demonstrated good
skin hygiene, e,g
wash thoroughly and
pat dry carefully.

Intact skin or
minimized presence of
wound.

Instructed family to
maintain clean, dry
clothes, preferably
cotton fabric (any Tshirt).
Emphasized
importance of adequate
nutritional fluid intake.
Demonstrated to the
family members on how
to make a guava
decoction to apply to the
wounds alternative
disinfectant.
Instructed family to
clip and file nails
regularly.
Provide and applied
wound dressings
carefully.

Rationale
Establishes comparative
baseline providing
opportunity for timely
intervention.
Maintaining clean, dry
skin provides a barrier
to infection. Patting
skin dry instead of
rubbing reduces risk of
dermal trauma to
fragile skin..
Skin friction caused by
stiff or rough clothes leads
to irritation of fragile skin
and increases risk for
infection.
Improve nutrition and
hydration will improve skin
condition.
Providing the family with
alternative solution assist
them in optimal healing
with less expensive
resources..
Long and rough nails
increase risk of skin
damage
Wound dressing protect
the wound and the
surrounding tissues.

Evaluation
After 8 hrs n u r s i n g
i n t e r v e n t i o n , the
client was able to
display improvement in
wound healing as
evidenced by:
Minimized presence of
wounds.
Several wounds have
dried up.

Assessment
Subjective :
masakit yung
kanang paa ko
as verbalized by
the patient
Objective :
>Pain scale of 7
>facial grimace
>guarded
behaviour
>irritability
Vital Signs:
BP:130/90
mmHg
Temp:36.6 C
RR:24bpm
PR:82bpm

Diagnosis
Pain related to facial
grimace, guarded
behaviour and
irritability

Inferences

Planning
After 8 hours of
nursing interventions,
the patient will be
able to experience
gradual
reduction/relief of
pain.

Intervention
INDEPENDENT:
1. Instruct client to report
any
improvement/exacerbation
in pain experience.
2. Encourage verbalization
of feelings about the pain.
3. Encourage and assist
client to do deep breathing
exercises.
4. Provide comfort
measures to provide
nonpharmacological pain
management.
COLLABORATIVE:
1.Administer
medications(particularly
analgesics) as prescribed

Rationale
INDEPENDENT:
1. Unrelieved pain can
create other problems
such as anger, anxiety,
immobility, respiratory
problems, and delay in
healing.
2. Only the client can
judge the level and
distress of pain; pain
management should be
a team approach that
includes the client. Very
few people lie about
pain.
3. Deep breathing for
relaxation is easy to
learn and contributes to
pain relief and/or
reduction by reducing
muscle tension and
anxiety.
4. To provide
nonpharmacologic pain
management
COLLABORATIVE:
Necessary for treatment
of the underlying cause.

Evaluation
After 8 hours the
patient feeling of
pain will be lessen
from 7 to 3.