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Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation


Following a 3-day  Assessed skin.  Establishes At the end of the 3-day
Subjective: Impaired skin
nursing intervention, Noted color, turgor, comparative nursing intervention,
“May mga sugat ako.” integrity
related to the client will be able and sensation. baseline providing the client was able to
as verbalized by the inflammatory
to display improvement Described and opportunity for display improvement in
patient. response
secondary to in wound healing as measured wounds timely intervention. wound healing as
Objective: evidenced by: and observed evidenced by:
 Disruption of skin  Intact skin or changes.  Minimized presence
surface at the ® minimized of wounds.
lower extremity. presence of wound.  Demonstrated good  Maintaining clean,
 Several wounds
skin hygiene, e.g., dry skin provides a
 Wound is 5mm in  Wound is less than have dried up.
wash thoroughly barrier to infection.
diameter. 5mm in diameter.
and pat dry Patting skin dry  Minimized
 Localized erythema  Absence of redness carefully. instead of rubbing erythema.
or erythema. reduces risk of
 Purulent discharge  Minimized purulent
 Absence of dermal trauma to discharge.
 (+) pruritus on the
purulent discharge. fragile skin.
site of the wound.  Wounds are still at
 Absence of least 5mm in
 (+) pain  Instructed family to  Skin friction caused
itchiness. diameter. (Continue
maintain clean, dry by stiff or rough
cleaning the wound
clothes, preferably clothes leads to
with disinfectant)
cotton fabric (any T- irritation of fragile
shirt). skin and increases  Presence of
risk for infection. itchiness. (Continue

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

 Improved nutrition
 Emphasized and hydration will
importance of improve skin
adequate nutrition condition.
and fluid intake.
 Providing the family
 Demonstrated to with alternative
the family members solution assists
on how to make a them in optimal
guava decoction to healing with less instructing client to

apply to the wound expensive avoid scratching the

as alternative resources. wound)

 Long and rough
 Instructed family to nails increase risk
clip and file nails of skin damage.
 Wound dressings
 Provided and protect the wound
applied wound and the
dressings carefully. surrounding

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation


Following a 3-day  Assessed each  The organism is At the end of the 3-day
Subjective: Impaired skin
nursing intervention, family member for easily transmitted nursing intervention,
“Makati po ang ulo integrity
(scalp) related the client will be able head lice. by direct physical the client was able to
ko.” as verbalized by to parasitic
to display timely contact. display timely healing
the patient. infestation
secondary to healing of scalp of scalp excoriations
Objective: excoriations without  Demonstrated to  Vinegar helps to without complications
 Presence of small, of the complications as family how to make remove any as evidenced by:
white flecks on hair evidenced by: a warm vinegar remaining nits or nit  Minimized
shaft at the back of  Absence of small, solution (1 cup shells from the hair excoriations on the
the head (eggs of white flecks on hair vinegar mixed with shaft. scalp.
lice). shaft (egg lice). 1 cup water).
 Minimized itchiness
 Pruritus on the  Absence of pruritus on the scalp.
 Combed the  Fine-toothed combs
scalp. on the scalp.
 Presence of egg
patient’s hair help remove nit
 Excoriation on the  Absence of lice (Continue
thoroughly with a shells from the hair
scalp. excoriations on the combing hair with
fine-toothed comb shaft and reduces
scalp. fine-toothed comb).
 Rough, dry hair. dipped in vinegar. risks for

 Instructed the  This condition

family to start the spreads rapidly.
immediately once

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

there is presence of
eggs at the hair

 Warned children
not to share combs,
 Head lice can also
brushes and hats
be transmitted
with other people.
indirectly through
infested combs,
brushes, wigs, hats
and beddings.
 Instructed family to
wash all clothing,
 Washing all
towels and
clothings in hot
beddings in hot
water prevents
water at least 54˚C
or hang under the
sun to dry.