Assessment Explanation of the Planning intervention Rationale Evaluation

problems
Nursing Diagnosis:Risk for infection- Vulnerable to LTO:  Assess Wound dressing.  To know what nursing
Risk for infection Related to invasions and multiplications of intervention is appropriate After 4-6 weeks of nursing
alteration in skin pathogenic organisms which After 4-6 weeks of nursing
integrity intervention, the patient is able
secondary to degloving injury may compromise health. intervention, patient will be able  Assess vital sign specially for the patient. to do Activities of daily living
to do ADL’s independently  Fever may indicate
temperature.
Degloving, also called avulsion, infection and It confirms
is a type of severe injury that
Subjective Data: the effectiveness of
happens when the top layers of STO1:
“May sugat yung right arm ko” your skin and tissue are ripped  Keep a sterile dressing treatment that is
After 8 hours of nursing
from the underlying muscle, After 8 hours of nursing technique during wound performed. intervention patient decreases
connective tissue, or bone. It can intervention patient will decrease  To reduce risk for
care. manifestation of pain such as
affect any body part, but it’s complaining about her wound
Objective Data:  Maintain Clean infection. grimacing and guarding
more common in the legs. dress.
Degloving injuries are often life- environment
>With Type 1 Diabetes mellitus STO2:  To minimize microbes that
threatening. This is because they  Encouraged to eat
>Presence of fluid on the wound involve large amounts of blood After 8 hours of nursing can infect the wound.
appropriate food to health
dressing  To fasten wound healing.
loss and tissue death. intervention patient will be able condition such as: green After 8 hours of nursing
>Degloving injury @ right hand to maintain normal temperature. intervention patient is able to
leafy foods and fruits
 Instructed to do deep maintain normal temperature
>T-36.3°C
breathing exercise
STO3:  It can help the body to
 Advice to avoid rubbing relax that can decrease After 8 hours of nursing
After 8 hours of nursing
and scratching. Provide intervention patient is able to
intervention patient will be able pain severity.
sleep and rest
to sleep and rest gloves or clip the nails if  Rubbing and scratching

necessary. can cause further injury

and delay healing.
STO4:
After 15 minutes of nursing
After 15 minutes of nursing
intervention patient verbalized
interventions patient verbalize
‘’naiintindihan ko na sige alam
understanding of medical and
ko na kung para saan mga yun’’
nursing intervention.