ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Impaired skin After 8 hours of INDEPENDENT: · Provide baseline After 8 hours of
“Nakagat ako ng integrity related nursing · Assess or information about nursing
aso habang to disruption of interventions, the document size, the wound and interventions, the
pauwi ako” (I got skin surface patient will color, depth of possible clues patient was able to
bitten by a dog on with destruction achieve timely wound and about the blood achieved timely
my way home) as of skin layers. wound healing. condition of circulation in the wound healing.
verbalized by the surrounding skin. affected area.
patient.
· Thoroughly wash · Washing the
OBJECTIVE: the wound as soon affected area is
¨ Facial as possible with very effective at
grimace soap and water for reducing the
¨ Irritability approximately five number of viral
¨ V/S taken as minutes. particles.
follows:
T: 37.2 · After washing an · To hasten the
P: 81 antiseptic solution spread of the viral
R: 21 should be applied disease in the
BP: 120/70 in the wound such surrounding area.
as povidone-iodine
and alcohol
(ethanol).

· Keeps skin free · To promote

from pressure. circulation.
· Implement contact · To reduce the risk
isolation for for cross-
respiratory contamination.
secretions,
especially saliva in
the duration of
illness.

· Investigate for · Deterioration in

change in the level of
mentation. consciousness
may indicate
worsening of the
patient’s
condition.

· Examine the · Identifies

wound daily. presence of
wound healing.

COLLABORATIVE
:
· To provide
· Administer anti protection and
tetanus and antirabies prevents the
immunoglobulin as spread of the
prescribed. disease.