Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Goal: ~Maintaining ~the goal is

~Demonstrated
“May mga ~Impaired After the clean, dry met.
sugat ako.” as skin integrity nursing 3 days good skin skin provides
verbalized by related to intervention a barrier to Because the
hygiene (ex.
the patient. inflammatory the client will infection. client is able
response be able to wash to display
secondary to display improvement
thoroughly and
Objective: infection. improvement in wound
~Disruption of in wound pat dry healing as
skin surface at healing. evidence by
carefully)
the right upper minimized
arm Objective: ~provide and ~ Wound presence of
~presence of ~the wound dressings wound.
applied
pain will be lessen protect the ~there s a
~the wound is in diameter wound wound and absent of
7mm in ~there will be the itching
dressing
distance an absent of surrounding ~absent of
~there has a erythema carefully tissues pain
presence of ~the presence ~ Improved ~several part
~Emphasized
erythema of wound will nutrition and of wound had
~presence of be minimize importance hydration dried up.
itchiness in the ~absence of will improve
of adequate
surrounding of itchiness skin
the wound nutrition and condition.
fluid intake.
-clean the ~so the
wound will
wound with
be not
disinfectant infected
and avoid
using dirty
dressing
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Dysuria Goal: ~promote ~ to avoid The goal is

related to After the proper infection and met.
“The client infection. intervention hygiene contamination Because the
verbalize the client (wash the to bacteria. client is able
that she has will be able anal and to urinate
experiencing to urinate perennial with out
pain upon with out area with pain.
urinating and pain soap and the client
their foul- water daily) didn’t feel
smelling Objective: pain in her
urine ~absent of back just
foul smell ~promote ~it will help below the
Objective: when fluid intake to flush or to rib cage, on
urinate get the one side of
~Restlessness ~absent of bacteria away her body
~Pain in the cloudy urine in the urinary
client’s back system.
just below
the rib cage,
on one side
of her body
~cloudy
urine in urine
examination