Assessment Nursing Scientific Planning Intervention Scientific Rationale Evaluation

Diagnosis Explanation

Subjective: Impaired skin Edema is caused by Independent: Partially

“Minamanas integrity reduce circulation Long term outcome: achieved
ang daliri ko related to into the extremities After 7 days of nursing • Assist the client in • Enhances commitment
tignan mo oh” reduced due to uterine intervention the client understanding and to plan optimizing The client was
as verbalized circulation pressure and general will be able to the following outcomes able to Verbalize
by the client. into the fluid retention. • Display timely medical regimen feelings of
extremities as healing of skin and developing increased self-
evidence by Reference: maternal lesion, pressure program of esteem and
edema on her and child volume one sores without preventive care and ability to manage
Objective: finger 5th edition chapter 11 complication daily maintaining. situation.
page 285 • Maintain optimal
Edema +4 in nutrition/physical “ah, kaya pala
the index well-being • Emphasize the • Impede lower ganito, alam ko
finger. importance of extremity na ang mga
Short outcome: proper fit clotting circulation and gagawin ko
Ring cannot fit After 2 days of nursing venous return. ngayon”, as
anymore into intervetion, the client will • Put feet high verbaluzed by
the index be able to: • To reduce the patient.
whenever possible
finger.
pressure to
• Verbalize • Take regular breaks veins.
Skin
feelings of from sitting or
pigmentation
increased standing
change.
self-esteem • A short walk
and ability to every so often
Disruption of
manage collaborative: will help keep
skin surface.
situation blood
When • Assess blood circulating.
palpated supply and
tenderness sensation of
occur. affective area.
• To evaluate
actual/potential
 for impairment
of circulation to
lower
extremities.

Reference: NANDA and

Maternal and child volume 15th
edition