Cues Nursing Rationale Goal and Intervention Rationale Evaluation

Diagnosis Objectives s

Subjective: Delayed Bedsores, Goal:

wound more After the 8 hour Goal Met.
shift of nursing
The client’s recovery accurately
interventions,
relative due to called the client will
verbalized: ineffective pressure have faster
-“Si mama therapeutic sores or wound recovery.
kasi hindi na regimen pressure
nakakagalaw manageme ulcers, are Objectives:
simula nung nt and self- areas of > Know the 1. Discuss pain control measures
causes of her if needed.
nadala siya care deficit damaged
condition and
dito sa as skin and follow steps on • To help patient coop
hospital dahil evidenced tissue that the proper towards the proper pain
sa sakit niya.” by develop when therapeutic management thus
-“Hindi ko rin impaired sustained management. minimizing pain suffering
naman physical pressure — and the ways of treating
masyado mobility. usually from them.
nalilinisan a bed or
sugat niya wheelchair —
2. Discuss Importance of
kasi sa umaga cuts off
adequate nutrition (especially
lang ako circulation to
fluids, proteins, vitamins B and C,
nakakabisita. vulnerable
iron and Calories).
Wala ako sa parts of your
gabi” body, • These provide patient
-“Eh hindi rin especially the information how nutrition
kaya ni nanay skin on your could elevate his chances
linisin magisa buttocks, hips of a faster recovery and
yun. Gumalaw and heels. wound healing.
nga magisa Without
nahihirapan adequate
3. Demonstrate appropriate
siya eh” blood flow,
positions for pressure relief.
the affected
Objective: tissue dies. • Enable client to minimize
Although further skin trauma thus
-Wound has people living promoting wound healing
foul smell with paralysis and establish physical
-Patient are especially >Be confined for mobility.
cannot move bed rest for
at risk,
by herself about 2-3 weeks
anyone who or more with
-Patient is 4. Establish a turning or
is bedridden, controlled
bedridden for repositioning schedule
uses a mobility on the
3 months now. wheelchair or affected part, • This provide patient’s a
-Female; 66 is unable to that is towards guide towards a proper
y/o change recovery. skin management
positions technique minimizing
without help more skin trauma and also
giving the patient
can develop
something to do thus
bedsores. promoting self-esteem.
Bedsores can 5. Instruct in wound assessment
develop and provide mechanism for
quickly, documenting
progress
rapidly and • Necessary to gather more
are often data concerning the
difficult to patient’s condition thus
identifying skin problems
heal.
clearly and promoting self-
esteem.
6. Emphasize principles of
asepsis, especially hand washing
and proper methods of handling
used dressings.

• To avoid possible infection

thus hindering the wound
healing process.

7. Provide information about

signs of wound infection and
order complications to report.

• Elevate the chances of

faster wound healing
which is important towards
avoiding further
complications or early
detections that requires
immediate interventions.

8. Demonstrate wound care

technique such as wound
cleansing and dressing changing.

• To provide the patient on

the correct procedures and
techniques of wound
caring.
 9. Identify potential sources of
skin trauma and means of
avoidance.

• Necessary to anticipate
future events thus
avoiding unexpected
complications or changes
vital to the patient’s
condition.

>Within 24
hours or less the 10. Support the use of
patient can appropriate defense mechanism.
express feeling
of relief and • To asses patient upon the
satisfaction upon proper management of
the treatment of stress or depressions
his condition. concerning on his
condition.

11. Encourage verbalization of

>Monitor Vital feelings, perceptions and fears.
signs every 4
hours. • To evaluate patients
perceptions upon his
condition and giving us
information towards
assessing client problems.

>To administrate
proper drugs
needed ordered 12. Monitor and document vital
by the physician. signs.
 • To establish baseline data.

13. Administer drugs according

to the physician’s order while
following the 10 right of
administrating Drugs.

• For faster wound healing

and to avoid errors during
administration.