Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Impaired skin Short-term: Assess site of skin The cause of the wound The patient as
Cue: integrity impairment and must be determined has developed
related to After an hour of determine cause. before appropriate an understanding
“ang sugat ko sa poor wound nursing interventions can be of etiology of the
likod… healing intervention, the implemented. This will condition as
nagsimula lang secondary to patient will: provide the basis for evidence by the
yan sa pigsa… Diabetes • verbalize additional testing and clients
tinignan pa nga mellitus type understanding evaluation to start the verbalization,
ng kapatid kong 2 of etiology and assessment process “ahh.. kaya pala
doctor yan.. appropriate Periodically (Baranoski & Ayello, 2003). lumala ng ganito
tapos isang interventions/sol remeasure/photogra ang sugat ko..at
linggo lang ang utions for the ph wound and To monitor progress of ang bagal
lumipas.. naging problem observe for wound healing gumaling dahil
ganyan na • exhibit complications sa mataas na
kalaki” as participation in sugar level.”
verbalized by the prevention Keep the area
client. measures and clean/dry, carefully To assist body’s natural The client exhibit
treatment dress wounds, process of repair participation in
program prevent infection, prevention
Objective Cue: and stimulate measures as
Long-term: circulation to evidenced by the
• Presence surrounding areas compliance with
of wound After 3 days of To remove nonviable, the appropriate
(stage III), nursing Assist with contaminated, or infected diet.
disruption intervention, the debridement as tissue
of patient will: indicated The wound is still
epidermal To protect the wound fresh but does
skin surface • Display timely Use appropriate and/or surrounding areas not exhibit
and healing of the barrier dressings. complications.
destruction wound without
of dermal complication. To enhance understanding
layers of the Reposition client on and cooperation * continue
skin, regular schedule, intervention until
revealing involving client in the wound heals
the fascia, reasons for and without
in the left decisions about complications.
upper back times and positions Optimizing nutritional
of the intake, including calories,
patient. Assess the client's fatty acids, protein, and
• Presence nutritional status. vitamins, is needed to
of grade 2 Refer for a promote wound healing
Wagner nutritional consult (Russell, 2001).
ulcer and/or institute
classificatio dietary supplements Enhances commitment to
n as necessary. plan, optimizing outcomes.