Assessment Diagnosis Planning Intervention Rationale Evaluation

~Maintainin
Subjective: Goal: g clean, dry ~the goal is
~Demonstrated
“May mga ~Impaired After the skin provides met.
sugat ako.” as skin integrity nursing 3 days good skin a barrier to
verbalized by related to intervention infection. Because the
hygiene (ex.
the patient. inflammatory the client will client is able
response be able to wash to display
secondary to display improvement
thoroughly and
Objective: infection. improvement in wound
~Disruption of in wound pat dry healing as
skin surface at healing. evidence by
carefully)
the right upper ~ Wound minimized
arm Objective: ~provide and dressings presence of
~presence of ~the wound protect the wound.
applied
pain will be lessen wound and ~there s a
~the wound is in diameter wound the absent of
7mm in ~there will be surrounding itching
dressing
distance an absent of tissues ~absent of
~there has a erythema carefully ~ Improved pain
presence of ~the presence nutrition and ~several part
~Emphasized
erythema of wound will hydration of wound had
~presence of be minimize importance will improve dried up.
itchiness in the ~absence of skin
of adequate
surrounding of itchiness condition.
the wound nutrition and
fluid intake.
~so the
-clean the wound will
be not
wound with
infected
disinfectant
and avoid
using dirty
dressing
Assessment Diagnosis Planning Interventio Rationale Evaluation
n

Subjective: Dysuria Goal: ~promote ~ to avoid The goal is

related to After the proper infection and met.
“The client infection. intervention hygiene contamination Because the
verbalize the client (wash the to bacteria. client is able
that she has will be able anal and to urinate
experiencing to urinate perennial with out
pain upon with out area with pain.
urinating and pain soap and the client
their foul- water daily) didn’t feel
smelling Objective: pain in her
urine ~absent of back just
foul smell ~promote ~it will help below the
Objective: when fluid intake to flush or to rib cage, on
urinate get the one side of
~Restlessness ~absent of bacteria away her body
~Pain in the cloudy urine in the urinary
client’s back system.
just below
the rib cage,
on one side
of her body
~cloudy
urine in urine
examination