Patient Name: A.B.

C Chief Complaint: Left Side Weakness Medical/Surgical Diagnosis: Cerebrovascular Accident Possible Ishemic Stroke
Bed No. 4G

ASSESSMENT NURSING OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective:
“Naas yay samad Impaired Skin Short Term: Independent:
sa iyang mga Integrity related After 6-8 hrs of  Assess between folds of skin,  Pressure ulcers After 8 hrs of nursing interventions
abaga” as to prolonged nursing interventions remove anti embolic stockings under medical patient:
verbalized by immobility and of nursing or devices & use a mirror to devices are
patient S.O unrelieved interventions, the see the heels. Also assess commonly - Reduce risk of infection as
Objectives: pressure client will: under oxygen tubing especially overlooked. evidenced by observing proper
 Localized secondary to on the ears & the cheek, and (Black, J. M., & hand washing technique before &
injury over CVA - Reduce risk under medical devices. Hawks, J. H. after wound care.
bony Scientific for infection (2009). Medical- - Minimized Purulent drainage
prominence Analysis: - Absence of surgical nursing: - Controlled itchiness and
 Dry & shallow The skin is the purulent Clinical management lessened the scratching on the
wound largest organ in drainage for positive area
 Reddish-pink the human body - Absence of outcomes (Vol. 1). A.
open/rupture and is a itchiness M. Keene (Ed.).  GOAL MET
blister protective
barrier. It After 4 days of nursing
protects the Long Term:  Increase the frequency of  To disperse interventions the client:
body from heat, After 3-4 days of turning (turning q2). Position pressure over - Experienced healing of tissue as
light, injury, nursing interventions, the client to stay off the time or evidenced by development of
and infection. the client will: ulcer. If there is no turning decreasing the granulation tissue & decrease in
Skin integrity surface without a pressure tissue load. ulcer size.
relates to skin  Experience ulcer, use a pressure (Black, J. M., & - Skin Integrity of the patient is
health. A skin healing of redistribution bed & continue Hawks, J. H. intact and has a good tissue
integrity ulcer/regain turning the client. (2009). Medical- perfusion
problem might skin integrity surgical nursing: GOAL MET
indicate the skin (reduce size Clinical
is damaged, of ulcer) management for
exposed to  Skin remains positive
injury or intact, as outcomes (Vol. 1). A.
inefficient to evidenced by M. Keene (Ed.). 
repair and the absence
recover of redness
normally. The over bony Heel covers do
key marker of prominences  Elevate heels off the bed by not relieve
quality care is and capillary using pillows or heel pressure, but they
Patient Name: A.B.C Chief Complaint: Left Side Weakness Medical/Surgical Diagnosis: Cerebrovascular Accident Possible Ishemic Stroke
Bed No. 4G

the maintenance refill less elevation buttocks. can reduce

of skin integrity than 6 friction.
and prevention seconds over . (Black, J. M., &
of pressure areas of Hawks, J. H.
ulcers. With this, redness. (2009). Medical-
the nurse must surgical nursing:
be aware of Clinical management
identifying at- for positive
risk individuals outcomes (Vol. 1). A.
and the myriad M. Keene (Ed.). 
factors that
place patients at
risk for skin Dependent: To prevent
damage. Prevent the ulcer from being malnutrition &
exposed to urine & feces. Use delayed healing.
indwelling catheters, bowel (Doenges, M. E.,
Pressure, shear, containment systems, & topical Moorhouse, M. F., &
and friction from creams or dressings. Murr, A. C. (2016)
immobility put
To prevent
an individual at Supplement the diet with contamination/sp
risk for altered vitamins & minerals. Vitamins C read of infection
skin integrity. and zinc are commonly (Doenges, M. E.,
Patients who are prescribed. Moorhouse, M. F., &
overweight,
Murr, A. C. (2016)
paralyzed,
with spinal
cord injuries,
 To promote
those who are
wound healing on
bedridden and Provide oral supplementations, clients who do not
confined to tube-feedings or have adequate
wheelchairs, and hyperalimentation to achieve calories.
those with positive nitrogen balance. (Doenges, M. E.,
edema are also
Moorhouse, M. F., &
at highest risk
Murr, A. C. (2016)
for altered skin
integrity. Other
factors that
hasten skin
Patient Name: A.B.C Chief Complaint: Left Side Weakness Medical/Surgical Diagnosis: Cerebrovascular Accident Possible Ishemic Stroke
Bed No. 4G

breakdown Pressure ulcers

include age, the cannot heal in
normal loss of Collaborative: clients with
elasticity,  Ensure adequate dietary severe
inadequate intake. Review dietician’s malnutrition.
nutrition, (Doenges, M. E.,
environmental Moorhouse, M. F.,
moisture, and
vascular & Murr, A. C.
insufficiency. (2016)
Special beds,
mattresses, and
other useful
devices provide
pressure relief
and pressure
redistribution.

Reference:
Matos, A. C. G.
T., Carvalho, E. S.
D. S., Passos, S.
D. S. S., & Silva,
R. S. D. (2018).
Family caregivers
challenges about
caring for
children with
impaired skin
integrity. Escola
Anna
Nery, 22(4).
Patient Name: A.B.C Chief Complaint: Left Side Weakness Medical/Surgical Diagnosis: Cerebrovascular Accident Possible Ishemic Stroke
Bed No. 4G

References:
Matos, A. C. G. T., Carvalho, E. S. D. S., Passos, S. D. S. S., & Silva, R. S. D. (2018). Family caregivers challenges
about caring for children with impaired skin integrity. Escola Anna Nery, 22(4).

Ackley, B. J., Ladwig, G. B., Msn, R. N., Makic, M. B. F., Martinez-Kratz, M., & Zanotti, M. (2019). Nursing
Diagnosis Handbook E-Book: An Evidence-Based Guide to Planning Care. Mosby.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurse’s pocket  guide: Diagnoses, prioritized
interventions, and rationales. FA Davis.