Cues Nursing Rationale Goals and Nursing Rationale Evaluation

Diagnosis Objectives Intervention

Subjective: Body image A disturbance After 30 Independent: -extent of response After 30
“halata masyado disturbance or alteration in minutes of -Assess is more related to the minutes of
ung sugat ko sa related to the attitude of nursing perception of valve or importance nursing
mukha at hindi alteration person has intervention, change in patient places on the intervention,
pa ako masyado structure about the the patient will structure/function part of function than the patient
makapagsalita. and/or actual or be able to: of body part. the actual value or was able to:
function. perceived importance.
structure or Demonstrate -Acknowledge Demonstrate
Objective: function of all enhanced normally of -stages of grief over enhanced
- Irritable or part of the body image emotional loss of a body part or body image
- Always body. This and self- response to function are normal, and self-
looking for attitude is esteem as actual or and typically involve esteem as
a change dynamic and evidenced by perceived change a period of denial. evidenced by
on altered ability to look in body ability to look
wounds. through at, touch, talk structure/function. at, touch, talk
interaction about, and -patients may about, and
with other care for actual -Help patient perceive changes care for actual
persons and or perceived identify actual that are not or perceived
situations and altered body changes present/real. altered body
is influenced part/function. part/function.
by age and - Evaluate the
developmental After 4-8hours - Evaluate the patient’s behavior
level of nursing patient’s behavior regarding the actual
interventions, regarding the or perceived
patient will be actual or changed body part or
able to perceived function.
incorporate changed body
changes into part or function.
self-concept
without - Assist the - The more
negating self- patient in noticeable the
esteem and incorporating change in body
will be able to actual changes structure or function,
verbalize into ADLs, social the more anxious the
acceptance of life, interpersonal patient may have
self in relationships, and about the response
situation. occupational of others to the
activities. change.
Opportunities for
positive feedback
and success in social
situations may
hasten adaptation.
ASSESSMENT INTERVENTION PLANNING INTERVENTION RATIONALE EVALUATION

Subjective : Impaired Skin Short Term: - Assess site of - Redness, •Responses to

• “Ang laki ng Integrity After 6-8 hrs of impaired tissue swelling, pain, interventions/
sugat ko’, as Related to skin nursing integrity and its burning, and teaching plans and
verbalized by the grafting interventions of condition. itching are actions performed.
patient. secondary to nursing indication of •Attainment/progress
large interventions, the inflammation and toward desired
Objective: hemangioma client will: the body’s outcome(s)
• Presence present at right immune system •Modifications of
of post skin graft lower leg. -Have reduced response to plan of care.
at right lower leg risk of further localized tissue
impairment of skin trauma or
• Disruption integrity impaired tissue
of skin surface -Patient will integrity.
(epidermis) demonstrate
understanding & - Assess - These findings
skill in care of characteristics of will give
wound wound, including information on
color, size extent of the
(length, width, impaired tissue
Long Term: depth), drainage, integrity or injury.
After 3-4 days of and odor.
nursing
interventions, the - Assess changes - Fever is a
client will: in body systemic
temperature, manifestation of
• Experience specifically inflammation and
healing of regain increased in body may indicate the
skin integrity temperature. presence of
• Reduce infection.
risk for infection - Assess patient’s - Inadequate
nutritional status; nutritional intake
refer for a places the
nutritional patient at risk for
consultation skin breakdown
and/or institute and
dietary compromises
supplements. healing further
causing impaired
tissue integrity.
- Keep a sterile - This technique
dressing reduces the risk
technique during of infection in
wound care. impaired tissue
integrity.