Assessment Subjective: May mga sugat ako. as verbalized by the patient.

Objective: Disruption of skin surface Localized erythema (+) pain (+) itchiness

Diagnosis Impaired skin integrity related to inflammatory response secondary to infection.

Inference

Planning After 8 hours of nursing intervention, the client will be able to display improvement in wound healing as evidenced by: Intact skin or minimized presence of wound. Absence of redness or erythema. Absence of itchiness.

Intervention Assessed skin. Noted color, turgor, and sensation. Described and measured wounds and observed changes.

Rationale Establishes comparative baseline providing opportunity for timely intervention. Maintaining

Evaluation After 8 hours of nursing intervention, the client was able to display improvement in wound healing as evidenced by: Several wounds have dried up. Minimized erythema. Absence of pain and itchiness.

Demonstrated good skin hygiene, e.g., wash thoroughly and pat dry carefully.

clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin.

 Instructed family to maintain clean, dry clothes, preferably cotton fabric (any Tshirt). Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for infection. Emphasized importance of adequate nutrition and fluid intake. Improved nutrition and hydration will improve skin condition.