ASSESSMENT NURSING PLANNING INTERVENTION EVALUATION

DIAGNOSIS
OBJECTIVES: Impaired skin After nursing  Assess the
integrity related intervention, wound: location, After 8 hours of
to decreased the patient will measurement, nursing
circulation to be able to tissue type/color, interventions, the
lower drainage/odor, patient was able to
extremities skin and pain identify nursing
manifested by: interventions to
Disruption of  Provide reduce the risk of
skin surface continued wound infection.
(+) swelling care with dakin’s
SUBJECTIVES: (+) redness solution.
(+) poor skin
Disruption of skin turgor  Keep the skin
surface (+) dry skin dry, and the
(+) Edema @ R linens also dry
(+) swelling foot and wrinkle free.
(+) redness
(+) poor skin turgor  Keep right foot
(+) dry skin elevated.
(+) Edema @ R foot
 Avoid pressure
in right heel.

 Encourage
adequate dietary
and fluid intake
of 3000ml per
day.

 Promote health
teaching on
taking
medications and
ways how to
clean his wound.
 NURSING PLANNING INTERVENTION RATIONALE EVALUATION
ASSESSMENT DIAGIS
OBJECTIVES: Fluid volume After 8 hours  Monitored V/S Cardiac
deficient of nursing and recorded. neuropathy may
“Madalas ako related to intervention block reflexes that
mauhaw” hyperglycemia the patient will  Assess skin normally increase
evidence by: demonstrate turgor heart rate.
Dry skin adequate  And mucous
turgor hydration as membranes. Indicators of level
SUBJECTIVES: Dry oral evidenced by of hydration,
mucous stable v/s,  Monitored intake adequate
Frequent urination membrane goods skin and output. circulating
Dry skin turgor Crack lips turgor and volume.
Dry oral mucous Dry skin appropriate  Maintain fluid
membrane thirsty urinary output intake of at least To estimate of
Crack lips and 2500ml/day volume
Dry skin electrolytes replacement
thirsty levels within  Monitored needs, kidney
CBG results= 400 normal range. weight weekly function and
mg/dL effectiveness of
Intake- 3600 ml theraphy.
Output- 2500 ml  Encourage to
have adequate To maintain
hydration.
rest periods.
To Identify if the
patient loss or
gain weigh

Promote
comfortable
environment.
 ASSESSMENT NURSING PLANNING INTERVENTION EVALUATION
DIAGNOSIS
OBJECTIVES: Imbalanced After 8 hours Independent: Goal partially met.
“ Laki po ng pinayat nutrion less of nursing  Monitor and The client was able to
ko, mataba kasi ako than body intervention, record vital signs demonstrate
dati” normal the patient behaviors and
related to will:  Monitor and lifestyle changes such
inability to record I & O as food choices. The
utilize nutrients General: results of blood
to meet Be able to be glucose test are
metabolic free of signs of  Assess causative fluctuating from
needs as malnutrition factors normal to higher
manifested by contributing to value.
increased thirst, Specific: imbalanced
SUBJECTIVES: frequent Demonstrate nutrition
urination and behaviors,
 Increased hyperglycemia. lifestyle  Discuss eating
thirst noted changes such habits and
 Frequent as food encourage
urination choices diabetic diet as
 Blood Display prescribed by the
glucose-364 normalization Doctor
mg/dL of blood
 Weight: 51 glucose test  Educate the
kg. client
regarding the
importance of
eating
healthy food.

 Plan with the

client his desired
meals.
 Discourage
beverages that
are caffeinated or
carbonated.
These may
decrease appetite
and lead to early

 Instruct client to
 limit sugar
intake.

 Instruct client to
balance
carbohydrate and
protein intake

 Encouraged to
establish regular
eating habits.

 Encourage to
have adequate
rest periods.

 Dependent:
Administer
medications
prescribed by the
physician such as
insulin
injections.