ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

S: “Palagyan Risk for Immobility, which After 8 hours of -Assess general After 8 hours of
naman po ng Impaired leads to pressure, nursing care condition of the nursing care
ointment Skin Integrity shear, and friction, is intervention, skin intervention,
yung sa gilid r/t physical the factor most likely client/family -Assess for -Skin stretched client/family
po ng puwet immobilizati to put an individual at member will be edema tautly over member was
ni nanay, on as risk for altered skin able to: edematous tissue is able to:
nagkasugat manifested integrity. Advanced at risk for
na kasi sa by bed sores age; the normal loss -exhibit timely impairment. -exhibited
may of elasticity; healing of timely healing
puwetan inadequate nutrition; pressure sores -Assess for fecal -Use of diapers and of pressure
nya.” environmental and/or urinary incontinence pads sores
moisture, especially -apply proper incontinence. with plastic liners
O: from incontinence; wound care traps moisture and -applied proper
Patient’s and vascular hastens breakdown. wound care
skin surface insufficiency
has potentiate the effects -Apply -for wound healing
disruption of pressure and appropriate
with a length hasten the dressing such as
of 15 inches development of skin gauze
with wound breakdown. Groups -Replace new -Use of diapers and
on the left of persons with the diapers if incontinence pads
cheek of the highest risk for needed with plastic liners
buttocks. altered skin integrity traps moisture and
are the spinal cord hastens breakdown.
injured, those who -prevents sweating
are confined to bed -Apply powder
or wheelchair for to around the
prolonged periods of affected site -for more rapidly
time, those with -Administer healing, aid in skin
edema, and those clindamycin and healing
who have altered topical
sensation that medications
triggers the normal -Assist -For easier work
protective weight nurse/health
shifting. care provider
when mobilizing
the patient

-Report -to assist in

evaluation of the developing plan of
wound to other care
health care team

-Teach family -for independent

member on promotion of healing
proper caring of
the wound and
application of
ointment