ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION SCIENTIFIC EVALUATION

DIAGNOSIS EXPLANATION RATIONALE

Subjective: Risk for Skin Decreased muscle Short term: -Assess skin -this may indicate Achieved
Integrity r/t physical strength After 8hours of routinely, noting particular The client/SO was
“Lagi siyang immobility nursing moisture, color, and vulnerability able to do therapeutic
nakahiga”, stated by ↓ intervention, the elasticity regimens to prevent
the daughter client/SO will be skin breakdown
able to verbalize -Note presence of -that may impair skin
Body weakness understanding of conditions/situations integrity
treatment/therapy
Objective: regimen -Observe for
↓ reddened/blanched -Reduces likelihood
-neuromuscular areas or skin rashes, of progression to skin
impairment Irritability Long term: and institute breakdown
After 2days of treatment
-physical immobility nursing immediately
↓ intervention, the
client/SO will be -Provide adequate
Physical immobility able to demonstrate clothing/covers; -To prevent
behaviors/technique protect from drafts vasoconstriction
s to prevent skin
↓
breakdown -Emphasize
importance of -To maintain general
Risk for skin integrity
adequate good health and skin
nutritional/fluid turgor
intake

*Medical-Surgical
*Nursing Care
Nursing 11th Edition;
Plans;7th
Brunner &
Edition;Doenges,Mo
Suddarth”s
orehouse,Murr
 ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION SCIENTIFIA EVALUATION
DIAGNOSIS EXPLANATION RATIONALE

Subjective: Readiness for A pattern of Short term: -Assess degree of -Helps client to Achieved
enhanced power participating After 8hours of Mastery client has understand how he The client/SO was
knowingly in change nursing exhibited in his life has functioned in the able to express
that is sufficient for intervention, the past & what is needed readiness of enhanced
well-being and can be client/SO will be to improve power
strengthened. able to verbalize
knowledge of what -Provide accurate -Reinforces learning
changes he wants to verbal & written & promotes self-
Objective: make information about paced review
what is happening &
-having self- discuss with client
perception Long term::
After 2days of -Discuss importance -Messages are often
-indicate support nursing of client paying confusing/misinterpre
sufficient intervention, the attention to nonverbal ted when verbal and
client/So will be communication nonverbal
able to state communications are
readiness to take not congruent
power over own life
-Help client learn to -Promotes win-win
problem solve solutions
differences

*Nursing Care
*Nurse’s Pocket Plans;7th
Guide 11th Edition; Edition;Doenges,Mo
Doenges, Moorhouse, orehouse,Murr
Murr