EXPLANATION OF THE

ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION

PROBLEM

Subjective: Acute pain is an STO:  Perform an assessment of  Assessment of pain STO:

unpleasant sensory and pain to include location, experience is the first
“Masakit talaga yung emotional experience Within 8 hours of step in planning pain After 8 hours of nursing
characteristics, onset/
kamay ko.” Describe pain arising from actual or nursing intervention, management strategies. intervention, the client
duration, frequency,
as throbbing and sharp. potential tissue damage the client will report The most reliable source has reported that pain
quality, severity, of information about the
Rated pain 8/10. or described in terms of that pain reduce from reduced from 8 to 5 as
grimacing ( 0 – 10 scale) pain is the patient.
such damage; sudden or 8 to 5. verbalized by the patient
 Descriptive scales
slow onset of any such as a visual analogue
intensity from mild to can be utilized to
severe with an distinguish the degree
anticipated or of pain.
LTO: 
Objective: predictable end and a  Assess for signs and Attention to
duration of less than six symptoms relating to associated signs may help
Within 5 days of the nurse in evaluating LTO:
- Facial grimace months. nursing intervention, pain.
pain.
the patient will After 5 days of nursing
- Guarding intervention, the client
describe pain as  Observed for non-verbal  Observations may not
behavior
tolerable and shows cues be congruent with verbal described pain as minimal
-Irritable signs of ease. reports or may be only as evidenced by signs of
indicator present when ease and stable vital
-Vital signs: the client is unable to signs
verbalize
PR- 96
 Administer pain  Giving oral
BP- 130/80 medications such as
medication as prescribed NSAID’s may relieve pain
by the physician

 Provide comfort  For relaxation and to

help lessen the pain
measures, quiet
environment and calm
Diagnosis:
activities
Acute pain related to
tissue trauma as  Encourage diversional  Prevents boredom,
evidenced by facial activities and reduces muscle tension
grimacing relaxation techniques and an increase muscle
such as focused breathing strength
and imagine.

 Provide rest periods to  A peaceful and quiet

promote relief, sleep, environment may
and relaxation. facilitate rest.
 EXPLANATION OF THE
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
PROBLEM

Subjective: The skin is the most
extended organ of the
“Naputol na yung kanang human organism. It
kamay ko dahil sa has a multifunctional
aksidente na nangyari”
role (excretory,
protective,
temperature-regulat
ory, and sensory)
which gives a high
level of importance
Objective: in case of skin
injury. Skin can be
Degloving injury @
- damaged in the
right hand
following ways:
- Hemorrhagic
direct trauma,
discharge draining
stretching,
on the injured area
degloving and
- Destruction of skin
layers undermining during an
operation.
- Alteration in skin
integrity
STO> Within 8 hours of - Assess site of impaired tissue  Redness, swelling, pain, STO> After 8 hours of
effective nursing integrity and its condition burning and itching are effective nursing
intervention, indication of inflammation intervention, the
patient will and the body’s response to patient demonstrated
localized tissue trauma or
demonstrate understanding of plan
impaired tissue integrity
understanding of plan to heal tissue and
to heal tissue and - Assess characteristics of  These findings will give prevented further
prevent injury. wound, including color, size information on extent of the injury.
(length, width, depth), impaired tissue integrity
drainage, and odor or injury. Pale tissue color
is a sign of decreased
LTO> Within 5 days of oxygenation. Odor may be a
nursing intervention, result of presence of LTO> After 5 days of
patient will describe infection on the site; it
nursing intervention,
may also be coming from a
measures to protect
necrotic tissue. Serous patient was able to
and heal the tissue,
exudate from a wound is a displayed timely
including wound care.
normal part of inflammation healing on the injured
and must be differentiated area
without
from pus or purulent complications
discharge, which is present
in infection.

- Assess changes in body  Fever is a systemic

temperature specifically manifestation of
increased in body inflammation and may
temperature indicate the presence of
infection

- Assess the patient’s level of  Pain is part of the normal

distress inflammatory process. The
Diagnosis: extent and depth of injury
may affect pain sensations
Impaired skin integrity
related to degloving - Assess for signs and symptoms  Pain is part of the normal
injury relating to pain inflammatory process. The
extent and depth of injury
may affect pain sensations.

- Monitor status of skin around  Individualize plan is

wound. Monitor patients skin necessary according to
care practices, noting type patient’s skin condition,
of soap or other cleansing needs and preferences
 EXPLANATION OF THE
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
PROBLEMS

Nursing Diagnosis: Risk for infection-

Risk for infection Related Vulnerable to invasions STO> After 8 hours of
STO> Within 8 hours  Assess Wound dressing.  To know what nursing
to alteration in skin and multiplications of nursing intervention, the
integrity secondary to pathogenic organisms of effective nursing intervention is patient was free from any
degloving injury which may compromise interventions, the
appropriate for the signs of infections as
health. patient will be free from evidenced by normal body
any signs of infection patient.
temperature
Degloving, also called  Assess vital sign  Fever may indicate
Subjective Data: avulsion, is a type of
specially temperature. infection and It
“May sugat yung right arm severe injury that happens
when the top layers of your confirms the
ko”
skin and tissue are ripped LTO> Within 3 days of effectiveness of LTO> After 3 days of
from the underlying nursing intervention,
treatment that is nursing intervention, the
muscle, connective patient will achieve patient’s wound is slowly
Objective Data: timely wound healing and performed.
tissue, or bone. It can healing as evidenced by
>With Type 1 Diabetes affect any body part, but be free from hemorrhagic  Keep a sterile dressing  To reduce risk for minimal discharges on the
mellitus it’s more common in the discharge on the wound wound site
technique during wound infection.
legs. Degloving injuries site
>Presence of fluid on the are often care.
wound dressing life-threatening. This is  Maintain Clean  To minimize microbes
because they involve large
>Degloving injury @ right environment that can infect the
amounts of blood loss and
hand wound.
tissue death.
>T-36.3°C  Encouraged to eat  To fasten wound
appropriate food to healing.
health condition such as:
green leafy foods and
fruits
 Instructed to do deep  It can help the body
breathing exercise to relax that can
decrease pain
severity.
 Advice to avoid rubbing  Rubbing and
and scratching. Provide scratching can cause
gloves or clip the nails further injury and
if necessary. delay healing.