OBJECTIVE AND

NURSING DAY /
NO OUTCOME INTERVENTION RATIONAL IMPLEMENTAION EVALUATION
DIAGNOSTIC DATE
CRITERIA
1 Pain Associated With An After 1x8 hours of 1.Assess the 1. Know thw 30/07/19 1.Assess the causes of S : The patient
Open Wound nusrsing action, pain cuases of pain source and scale 08.42 pain comperhensively said there was
is expected to comprehensively of pain as a R/ there is a wound the still pain in the
Ds : The patient says pain decrease with the whole left shoulder wound
P: The presence of a expected results :
tumor tump 1.Vital Sign Is 2. Assess teh 2. Know the 08.42 2. Assessing the patients O : The patient
Q: Like pricked Within Normal patient’sn vital state of the body vital signs looks grimaced
R: Left shoulder Limits signs within normal R/ Blood presure: in pain scale : 3
S: 5 ( 0-10 ) - Blood presure: limits 100/60mmhg (0 – 10)
T: Dissapper arise , 5 120/80 mmhg Body temperatur:36.0oc
minutes Body temperatur:36,5 Pulse:90x/menit A : The problem
– 37,5 oc Respiration: 20x/meninute has not been
Do : The patient Pulse: 60 – 100 resolved
Patient looked x/menit
General condition: Respiration: 18 – 22 3. Give a 3. Appropriate 08.48 3. Give the patient a P : Continue
Awareness : x/mnt comfortable position can comfortable position intervention 2, 3,
composmentis 2. Facial expressions position reduce pressure R/ the patient is in supine 4 and 5
GCS:15 (e:4,v:5,m:6) look comfortable on the wound position
Vital sign: 3. the patient says Date : 30/07/19
Blood presure: pain is reduced At 14.00
100/60mmhg pain scale : 3 (0 -10) 4. Teach pain 4. Calms the 09.00 4. Teaches pain
Body temperature:36.0oc management patient so that management distraction
Pulse:90x/menit pain can be relaxation
Respiration: 20x/meninute reduced R/ the patient seems to
-there was an open wound take a deep breath using
on the shoulder ±7,9 cm x the nose then axhale
3,95 cm x5 cm slowly through the mouth
- there is pus and
moisrure 5. Continue 5. The medicine 09.42 5. Contiuned collaboration
- face looks grimaced with collaboration with works by with doctors in providing
pain doctors in pressing the medicine therapy
providing central point of R/ patients received
analgesic pain to reduce analgesic medicine
medicane therapy pain therapy

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 OBJECTIVE AND
DAY /
NO NURSING DIAGNOSTIC OUTCOME INTERVENTION RATIONAL IMPLEMENTAION EVALUATION
DATE
CRITERIA
2. Imparied skin interity After 2 x 24 hours 1.Observation of 1.The level of 10.00 1. Observe the state of the S : The patient
associated with pus nursing action,it is the location of teh skin integrity site’s color and odor said: his shoulder
expected that the wound color and supports wound R/ there is a wound on the was injured
DS : The patient said: his wound condition and odor healing left shoulder taht stands
shoulder was injured skin integrity will interventions out there is pus and smells
improve with the
DO : - The patient appears expected results : 2.Clean the 2. Prevent 10.00 2. Clean the patient’s O: Patient looked
open wound -Free skin tissue from patient’s wound infection wound wound size 7 cm
± 7,9 cm, x 3,95 cm x 5 the pus R/ the patient’s wound is x3,95cm,x5 cm
cm there is pus and - the wound is not cleaned with NaCL then open. There pus
moisture moist dried and tehn given a an moist
gauze that has been given
honey
A: The problem
3. Put a dressing 3. Preventing the 10.22 3. Dressing the patient has not benn
on the wound wound from R/ The patient’s wound is resolved
getting dirt covered with gauze
which can
hamper healing P:Continue
intervention

4. Teach patients 4. Increase 10.25 4. Teach patients and

and families how knowleadge families how to care for
to care for about handlinh wounds
wounds wound care R/ The patient looks to see
how to treat wounds and
understand how

5. Encourge the 5. Prevent the 10.30 5. Encourge the patient to

patient to wear wound from wear clean clothes if
clean clothes if getting dirt or possible
possible dust R/The patient does not
wear clothes because of
sweat

6.Continued 6. Treating 09.52 6. Continued collaboration

collaboration with medicine word’s with doctors in

21
doctors in towards the administering antibiotic
administering center of the medicine teraphy
antibiotic wound and treats R/ Metronidazole/500 mg/
medicine teraphy the wound from IV
the inside Ceftriaxone/1 gr/ IV

22
 OBJECTIVE AND
DAY /
NO NURSING DIAGNOSTIC OUTCOME INTERVENTION RATIONAL IMPLEMENTAION EVALUATION
DATE
CRITERIA
3 Self-care deficits related After taking nursing 1.Assess the 1.Find out the 08.47 1.Assess the cause of the S : Patient says
to actions 1 x 8 hours cause of the cause of the patient self-care deficit. : the body is
patient appear patient self-care self-care bath Result : fresher.
DS : Patient said : cleaner with the deficit. deficit. There is a wound on the
He had not taken a bath following criteria : left shoulder. O : The patient
in the hospital and only - face shows look :
wiped it with tissue. comfort. Rather clean.
- the patient body 2. Encourage the 2.Moist 08.47 2.Encourage the patien
DO : Patient appear : looks cleaner patien to change clothing will to change clothes. A : The
- Hair looks dirty clothes. cause prickly Result : problem has
- ears look dirty heat causes The patient understands not been
- There are dental caries skin irritation. the nurse’s resolved.
- pale and dry lips recommendations.
- Patient looked : P : Continue
Wound size 7 cm x 3,95 intervention
cm x 5 cm open. 3.Give 3.Assistance 09.15 3. The nurse helps wipe 2,3,4, and 5.
There pus an moist. assistance to provided can the patient body with
patient in taking relieve patients wet tissue.
self-care in fulfilling
bathing. self-care.

4.Provide 4. supporting or 10.00 4. Provide toiltries if

toiltries if fulfilling the needed.
needed. support R/ Nurses provide
facilities for toiletries
self-care
bathing.

5.Do wound 5.Prevent 10.00 5. The patient wound is

care. infection. cleaned and replaced
with a sterille dressing /

23
 gauze.

6.Do health 6.Improve 10.40 6. the nurse said that the

guidance to patient patient must maintain
patient. knowledge physical hygiene.
about the
importance of
maintaining
personal
hygiene.

24