ASSESSMEN NURSING RATIONALE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

T DIAGNOSIS

Subjective: P- Impaired Pressure on Short Term: Independent:

“meron na Skin Integrity soft tissues After 6-8 hrs of  Assess between folds of  Pressure After 8 hrs of
syang sugat E- related to between nursing skin, remove anti embolic ulcers under nursing
sa bandang pressure bony interventions of stockings or devices & use medical interventions
pwet, dahil sa ulcer prominences nursing a mirror to see the heels. devices are patient:
pagkakahiga secondary to ↓ interventions, Also assess under oxygen commonly - reduced risk
niya ng prolonged Compresses the client will: tubing especially on the overlooked. of further
matagal..” as immobility capillaries & ears & the cheek, beneath impairment of
verbalized by and occludes Have reduced splints and under medical  Reassessment skin integrity
the patient’s unrelieved blood flow risk of further devices. of ulcer is as evidenced
granddaughte pressure as ↓ impairment of  Note objective data of completed by no actual
r. S- evidenced Pressure not skin integrity pressure ulcer (stage, each time additional
by: relieved  Patient’ length, width, depth, dressing are tissue
Objectives: ↓ s caregivers wound bed appearance, changed or breakdown &
Stage II Microthrombi will drainage & condition of sooner if ulcer no persistent
 Stage II pressure formation demonstrate periulcer tissue) shows reddened
pressure ulcer @ L ↓ understandin manifestations areas
ulcer @ L &R + occlusion g & skill in of -patient’s
&R buttocks in capillaries care of deterioration. caregivers
buttocks  Localized & blood flow wound Analyses of demonstrated
 Localized injury over ↓ the trends in understanding
injury over bony Formation of healing are & skill in care
bony prominenc blister Long Term: important step of wound as
prominenc e ↓ After 3-4 days in assessment. evidenced by
 Increase the frequency
e  Dry & Rupture of of nursing  To disperse checking
of turning (turning q2).
 Dry & shallow blister interventions, pressure over pressure ulcer
Position the client to stay
shallow wound ↓ the client will: time or sites
off the ulcer. If there is no
wound + open decreasing frequently &
 Reddish- turning surface without a
 Reddish- wound  Experience the tissue cleansing the
pink pressure ulcer, use a
pink ↓ healing of load wound
open/ruptu pressure redistribution
open/ruptu Stage II ulcer/regain Heel covers do aseptically.
re blister bed & continue turning
re blister manifestation skin not relieve PARTIALLY
the client
s: integrity pressure, but MET
 Elevate heels off the
 Stage II (reduce size they can
bed by using pillows or
pressure of ulcer) reduce After 4 days of
heel elevation botts.
ulcer @ L  Reduce risk friction. nursing
&R for infection interventions
 Maintain head of bed @  To
buttocks the client:
the lowest elevation, if prevent
 Localized further - Experienced
client must have the head
injury over occurrence of healing of
elevated to prevent
 bony aspiration, reposition to pressure ulcer. tissue as
prominenc 30 degree lateral position. evidenced by
e Use seat cushions & development
Dry & assess sacral ulcers daily. of granulation
shallow  Follow body substance To reduce risk tissue &
wound isolation precautions; use of infection decrease in
 Reddish- clean gloves & clean ulcer size.
pink dressing for wound care. - Reduce risk of
open/ruptu Practicing proper hand infection as
re blister washing before & after evidenced by
wound care. To prevent observing
Reference: malnutrition & proper hand
Medical- Dependent/Collaborative: delayed washing
Surgical healing technique
NursingClini Ensure adequate dietary To prevent before & after
cal intake. Review dietician’s contamination/ wound care.
Managemen recommendations. spread of PARTIALLY
t for Positive  Prevent the ulcer from infection MET
Outcomes being exposed to urine &
Vol II, 8th feces. Use indwelling
edition by catheters, bowel  To promote
Joyce M. containment systems, & wound healing
Black pp. topical creams or dressings. on clients who
1209-1210 Supplement the diet with do not have
vitamins & minerals. adequate
Vitamins C and zinc are calories.
commonly prescribed.  Pressure
ulcers cannot
 Provide oral heal in clients
supplementations, tube- with severe
feedings or malnutrition.
hyperalimentation to achieve
positive nitrogen balance. To promote
Remove devitalized tissue faster healing
from the wound bed, except & reduce
in the avascular tissue or on infection
the heels. Began by
cleansing the ulcer bed with
normal saline, then use
appropriate technique for
debridement. Once the ulcer
is free of devitalized tissue,
apply dressing the keep the
wound bed moist & the
surrounding skin dry. Do not
use occlusive dressings on
ulcer.