ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Name of patient: Impaired skin After 8 hours of Independent: After 8 hours of

Jimlok, Aljan integrity related to applying nursing - Ascertain the - Identifies nursing
Ereno prolonged interventions, the attitude of areas to be interventions, the
immobility client will be able individual / addressed in patient’s level of
5 year-old male to participate in significant teaching cooperation
prevention other about plan and increased, as
Leukocyte: 12.80 measures and the condition. potential evidenced by:
treatment program referral - Seen
Objective: needs. cooperating
with
Vital signs taken - Inspect skin - To monitor significant
and recorded as on a daily progress of other in
follows: basis, wound doing
describing healing. interventions.
T: 37.8 C lesions and - Beddings
PR: 80 bpm changes always kept
RR: 25 bpm observed. dry
- Patient’s
- Keep the area - In order to position was
clean and dry, assist body’s frequently
carefully dress natural changed
wounds if process of
necessary. repair.

- Avoid use of - Moisture

plastic potentiates
materials and skin
remove wet breakdown /
linens integrity.
promptly.
 - Instructed to - Helpful in
always keep drying
beddings dry, wounds and
and to change to not have
position further
frequently. lesions.

Dependent:

- Assist the - Enhances

significant committment
other in to plan.
understanding:
Following
medical
regimen and
developing
program of
preventive
care and daily
maintenance.

- Assist both - To control

client and feelings of
significant helplessness
other to learn regarding the
reduction and current
alternate situation.
therapy
techniques
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Name of patient: Altered body After 8 hours of - Performed - To monitor After 8 hours of
Jimlok, Aljan temperature nursing nursing care changes or any nursing
Ereno interventions, the and development in interventions, the
patient will be able continuously patient’s patien maintained a
5 year-old male to msintain body monitored condition and body temperature
temperature within patient’s to maintain a within the normal
Leukocyte: 12.80 the normal range, vital signs to body range and
and will ensure a temperature experienced no
Objective: experience no normal body within a associated
associated temperature normal range. complications at
Received patient complications and a all.
awake, lying on wholistic
bed, with warm functional
and flushed skin. leve.

Vital signs taken - Monitored - To obtain a

and recorded as patient’s baseline data
follows: vital signs. and to check
changes or
T: 37.8 C progress
PR: 80 bpm regarding
RR: 25 bpm patient’s
condition.

- To reduce the
- Instructed to risk of
do proper acquiring
hand infection.
hygiene.
- Encouraged
to do tepid
sponge bath.
- To reduce
patient’s
- Monitor a hyperthermic
ventilatory condition.
effort.
- Ventilatorty
effort may be
impaired due
to
- Monitored hypermetabolic
sources of state.
fluid loss
such as - Fluid and
urine and electrolyte may
stool. be impaired
due to
dehydration.