Casimiro Andrei Orven

Elandag Clarinel
Gamboa Nikka Angel
Mempin Alyssa

Morales Brian
Pelaez Melissa
Santiago Rain
Sunga Jean Aubrey
 NURSING EXPECTED
DATE CUES NURSING OBJECTIVES NURSING
DIAGNOSIS OUTCOME
INTERVENTIONS RATIONALE

March Subjective: After 30 minutes to 1

21,2019 hour of nursing
 “Noong una Impaired skin integrity At the end of 30 minutes  Establishing rapport  To gain the trust and interventions the
Time wala pa akong related to trauma on to 1 hour of applying with the client cooperation patient was able to:
8:53 PM nararamdaman the epidermis layer of nursing intervention the
pero pagkatapos the skin at the left part patient will be able to:  Instruct and  Accurate information  Describe
ng isang minuto of the knee due to demonstrate about increase the patient’s ability measures needed
ang hirap vehicular accident as  Describe measures proper care of wound to manage therapy to promote healing
makagalaw non evidenced by several needed to promote including hand washing, independently and reduce “kakain ako ng
mahirap din wounds (scratches and healing of the injured dressing changes, and the risk of infection pagkain na
ihakbang, lesions) with height of skin and prevent application of topical mayaman sa
maligo at five centimeter at the complications medications to the client protein para
matulog” as left leg, affected areas and family member mabilis at
verbalized by are warm, tender to  Identify importance of  Redness, swelling, pain, maganda ang pag
the patient. touch and redness wound care and other  Assess site of skin injury burning and itching are an hilom ng aking
found around the infection control and its condition, indication of inflammation sugat” as
 “Medyo makirot wound measures including characteristics and body’s immune system verbalized by the
ung mga sugat of wound (color, length, response to localized skin patient
ko pero kaya ko  Demonstrate proper width, depth drainage injury.
naman ung kirot” wound care and and odor)  Identified
as verbalized by SCIENTIFIC application of topical  To document status and importance of
the patient EXPLANATION: medications.  Photograph lesions as provide a visual baseline for wound care “
appropriate ( data privacy future comparison importante pala na
 With pain scale • Impaired Skin  Return Demonstration with consent from the lagi ko nililinis ung
of 3/10 Integrity related to client)  Dressing replaces the sugat ko para
surgical incision and protective function of injured maiwasan ang
per-cutaneous drain skin during the healing infection, isa pla
placement as  Provide wound care process kailangan iwasan
Objective evidenced by everyday as order using ang pagkamot sa
 Several minor disruption of epidermis institutional protocol  Technique reduces the risk aking sugat ng
scratches and and dermal tissue. of infection in impaired skin maiwasan ang
abrasions found in integrity lalong pag
the left knee Reference: Nurse’s  Use sterile dressing susugat” as
 Watery discharge on Pocket Guide, technique during wound  Rubbing and scratching can verbalized by the
some injured site Diagnoses, Prioritiized care cause further injury and patient
with a height of five Interventions, and delay healing
centimeter long Rationales. M.  Advice the patient to  Demonstrate
found in the Doenges, M . avoid rubbing and  A high protein diet is proper wound care
 superficial part of Moorhouse A. scratching, clip the nails
the skin. Murr.12th Edition if necessary
 Affected areas are  Encourage a diet that
warm, tender to meets nutritional needs,
touch encourage high protein
diet
 Redness found
around the wounds.  Advice skin and wound
assessment and ways to
monitor for signs and
symptoms of infection,
complications and
healing.
needed to promote healing
 Early assessment and
intervention help prevent
the development of
complication like for
example, wound infection
 Therefore the
nursing goal
was fully met