ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

O:
 Bedsores at the Impaired skin To display timely  Protect the  The peripheral After 8 hours of
right buttocks integrity related to healing of bed sores skin from circulation of nursing intervention
 Visible bed sores at the right without complications trauma and pad places the affected area is
maculopopular buttocks. within the hospital prolonged patient at high maintained dry and
rashes all over stay. pressure risk for injury cleaned. Bed sores
the body are still noted.
 Dry and scaly
skin  Keep the  To prevent
 Scratching of affected area infection
the skin dry always
 Dirty nails,
 Note for  Scratching can
untrimmed
cause lesions
scratching
and open sores
skin and of
keeping
finger nails
short and
clean

 Put mittens  Mittens

prevent
on hand if
excessive
necessary scratching
 Note the
patient’s  Immobility is
ability to greater risk for
move skin
breakdown
 Position the
patient in the  To avoid
non-affected pressure on
area the affected
area causing
for severity