Cebu Institute of Technoloy

University
N. Bacalso Ave., Cebu City Philippines
ASSESSMENT NURSING SCIENTIFIC GOAL OF OUTCOMES NURSING RATIONALE EVALUATION
DIAGNOSIS BASIS CARE CRITERIA INTERVENTION
Subjective: Impaired skin Cellulitis takes Short-Term Goal:  Absence of INDEPENDENT  Proper skin care  Patient
“Sakit akoa bukton” integrity related to place after the skin After 4 hours of redness,  Identify includes washing the displayed
injury of the skin as is disrupted and rendering nursing warmth, underlying skin with warm water timely healing
Objective: evidenced by microorganisms intervention, swelling, cause/conditio and mild soap. The area of wounds
Tenderness at the reports of pain and invade the patient will be able and n involved. may or may not be without
right at arm and pain itching. subcutaneous to participate in tenderness  Note changes covered with a dressing complication.
is felt at the site. tissues. Most preventive at the site of in skin color to prevent further  Patient
Skin sore or rash commonly the measures and cellulitis. texture and damage. Sometimes the maintained
due to the invasion infective agent is treatment program.  Reduction turgor. skin will weep and optimal
of pathogens, the beta-haemolytic in pain  Determine should be wrapped to nutrition and
skin develops rashes streptococci (most Long-Term Goal: intensity or depth of protect bedding and physical well-
over the affected often) or After 1 week the pain-free injury/damage clothing. being.
site. staphylococcus client will be taught status. to  Certain wound care  Patient
aureus (including what part of her  Absence of integumentary techniques such as participated in
Signs and methycillin- body is at most risk purulent system. packing, debridement, prevention
Symptoms: resistant). for skin drainage,  Inspect skin and incision and measures and
Redness, warmth, breakdown. and the on a daily basis drainage are also treatment
swelling, tenderness wound describing painful. General program.
shows signs lesions and discomfort from  Patient
of healing changes swelling and burning verbalized
 Completion observed. can be eased with a feelings of
of the cool, damp cloth. increased self-
prescribed DEPENDENT:  If the patient is esteem.
course of  Administer immobile or is unable to
medications. prescribed guard against further
analgesics as skin breakdown take
ordered. care when turning and
 Administer repositioning. Ensure
antibiotics as the patient is not putting
prescribed by pressure on the area.
the physician.  Swelling can be
alleviated by elevating
the extremity. Cellulitis
often occurs in the
lower leg but can affect
the arms, face, and other
areas. Prop extremities
on pillows.
ASSESSMENT NURSING SCIENTIFIC GOAL OF OUTCOMES NURSING RATIONALE EVALUATION
DIAGNOSIS BASIS CARE CRITERIA INTERVENTION
Objective: Impaired Skin Short-Term Goal: INDEPENDENT
Integrity related to DEPENDENT:
bacterial invasion as
evidenced by Long-Term Goal:
cellulitis.