ASSESSMENT NURSING INFERENCE GOAL INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Impaired skin Altered epidermis After 30 mins. of 1) Emphasize  To avoid possible After 30 mins. of
“May tahi ako”, as integrity related to due to episiotomy nursing intervention, principles of infection nursing intervention,
verbalized by the episiotomy wound wound. the patient will hand washing the patient
patient. secondary to post understand the 2) Keep the area  Moistures harbors understood the
Objective: NSD importance of caring clean and dry microorganisms importance of caring
 Presence of the incision site and  To decrease risk the incision site and
secretions be able to manage 3) Instruct for infection was able to managed
 Incision on situation. patient to situation.
right mediolateral maintain clean,  Long and rough
dry clothes nails increases
4) Instruct risk of further
patient to clip impaired skin
nails regularly integrity
 To increase
5) Inform compliance
patient the
purpose of self-
care practices

 To promote wound
6) Advise healing
patient to eat
foods high in
protein such as
lean meat, fish,
etc