ASSESSMENT NURSING SCIENTIFIC PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS RATIONALE
Impaired skin Alterations in blood D.O. INDEPENDENT D.O.
integrity r/t large flow After 1 wk of nursing At the end of the 1
O> altered level of vessel destruction as / interventions, the Assessed skin. Noted Establishes week nursing
consciousness evidenced by blood viscosity, patient will be able to color, turgor, and comparative baseline intervention, the client
alteration in pressure increased platelet display improvement sensation. Described providing opportunity was able to display
>generalized distribution, aggregation, and in wound healing as wounds and observed for timely improvement in
weakness ulceration accelerated capillary evidenced by: changes. intervention. wound healing as
endothelial growth (Doenges) evidenced by:
>numbness of the / Intact skin and
lower extremities large vessel Minimized presence Demonstrated good Maintaining clean, dry Intact skin
destruction of wound. skin hygiene, e.g., skin provides a barrier Minimized presence
>disruption of skin / Absence of itchiness, wash thoroughly and to infection. Patting of wounds,
layers at the left leg loss of foot sensation redness pat dry carefully. skin dry instead of Absence of redness
/ rubbing reduces risk or itchiness
>edema on both upper completely unnoticed S.T.O. of dermal trauma to
and lower extremities cuts or trauma to the After 8 hours of fragile skin. (Brunner)
skin nursing intervention S.T.O.
>muscle weakness / the patient will be Instructed family to Skin friction caused After 8 hours of
blood glucose able to: maintain clean, dry by stiff or rough nursing intervention
>diagnosed DM concentration may clothes preferably clothes leads to the patient will be able
patient slow or even reverse Participate in cotton fabric irritation of fragile to:
this pathological prevention measures skin and increases risk
process and treatment for infection. (Kozier) Participate in
/ program prevention measures
Slow wound healing Demonstrate proper Emphasize Improved nutrition and treatment program
process wound care c/o importance of and hydration will Demonstrate proper
watcher adequate nutrition and improved skin wound care c/o
fluid intake. condition. (Doenges) watcher
Assists them in
Demonstrate to family optimal healing with
members how to make less expensive
a guava decoction to resources. (taylor)
apply in the wound as
alternative
disinfectant. Long and rough nails
increases risk of skin
Instruct the family to damage. (Kozier)
clip and file the nails
regularly. .

Provided and applied Wound dressings

wound dressings protect the wound and
carefully. the surrounding
tissues. (Doenges)

Apply lotion on legs To prevent dryness of

skin (Kozier)

COLLABORATIVE

Note laboratory To assess causative

results pertinent to factors. (Kozier)
causative factors
(Hb/Hct, blood
glucose, albumin)
To clean the wounded
Assist with area and prevents
debridement therapy contamination.
as indicated. (Brunner)