CUES

PROBLEM

SCIENTIFIC REASON Inflammatory response to wound is the first stage of wound healing process It is normally followed by two further phases: regeneration and maturation. Inflammation is characterized by the classic signs of heat and redness, pain and swelling, raised temperature and fever. (Source: http://www.nursingti mes.net/home/clini cal-zones/woundcare/understanding -woundinflammation/20536

DESIRED OUTCOME Short term goal: After 6 hours of nursing intervention patient will able to participate in prevention and treatment of wound. Long term goal: After 3-5 days of nursing intervention patient will be able to display timely healing of the wound without complication.

INTERVENTION/ RATIONALE Obtain history of condition including original site/characteristic of lesions and changes of the skin. Note Skin color, texture and turgor. Palpate skin lesion for texture, temperature and hydration. To assess the skin for possible complications. Determine degree and depth of injury or damage to integumentary system. To determine the time of healing of the wound. Photograph of lesion as appropriate. To document status and provide

EVALUATION STANDARD CRITERIA

Subjective: may sugat ako sa may bandang ibabang kaliwa ng tyan as verbalized by the patient Objective: (+) penetrating wound with approx. 1x1 cm on left hemiabdomen (+) swelling (+) redness

Impaired skin integrity related to inflammatory response secondary to gunshot wound

The client has good skin integrity and no presence of skin wound and lesion.

The client displays timely healing of the wound and has remained free from wound infection.

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baseline for future comparisons. Note odors emitted from the wound. To assess wound for presence of infection. Inspect skin on a daily basis, describing wound characteristic and changes observed. To monitor progress of wound healing. Keep the area clean and dry, carefully dress wound and prevent infection. To assist bodys natural process of repair. Use appropriate wound coverings and skin-protective agents for open, draining wound. To protect the wound and

surrounding of the tissue. Apply appropriate dressing. For proper wound healing. Reposition client on regular schedule. To enhance understanding and cooperation. Encourage early ambulation or mobilization. To promote circulation and reduces risks associated with immobility. Provide optimum nutrition, including vitamin (e.g., A, C, D, and E) and increase protein intake. To provide a positive nitrogen balance to aid in skin and tissue healing.