ASSESSMENT

DIAGNOSIS

OBJECTIVES At the end of 1 hour of nursing interventons pt will be able to: - understand importance of wound dressing - show cooperaton on this healing regimen At the end of 4 hours of nursing interventions pt will be able to: - Demonstrates proper wound dressng, - verbalize less itchiness on site. - lessen redness on wound site.

IMPLEMENTATION RATIONALE Assess skin and note colo, skin turgor and sensation. Observe for any changes. Demonstrat good skin hygiene like washing wound thoroughly and pat dry gently. Emphasize the importannce of adequate nutrition and fluid intake Provide and apply wound dressing properly. To establish comperative baseline data. Maintain clean, dry skin that can proide a barrer to infection. Patting skin dry instead f rubbing reduces risk for dermal trauma to fragile skin . Proper nutrition and fluid intake will improve skin condition. Wound dressings protect the wound and te surrounding tissues that can aid to a faster healing.

EVALUATION At the end of 1 hour of nursing ntervention pt was able to understand importance of wound dressing and shows cooperation. At the end of 4 hours of nursing intervention pt demonstrates proper wound dressing, verbalizes less itchiiness and redness on site of wound.

SUBJECTIVE CUES: impaired skinintegrity Naa man na cyay related samad daghan kai sige toinflammatoryrespon man laag og daagan, se secondaryto infection

OBJECTIVE CUES: -Disruption of skin surface at the lower extremities. - itchiness on site of wound - redness on wound area.