Assessment Nursing Diagnosis Pathophysiology/ Planning Intervention Rationale Evaluation

Scientific
explanation

Pressure on soft INDEPENDENT: At the end of the 3-

Subjective: Infection related to
tissues between bony  Assessed skin.  Establishes day nursing
The patient chronic skin
Following a 3-day
breakage secondary prominences Noted color, comparative intervention, the
verbalized that to slow wound nursing
turgor, and baseline client was able to
"ang tagal ng di healing Ⅰ intervention, the
sensation. providing display
gumagaling itong Compress capilliaries client will be able to
Described and opportunity for improvement in
sugat ko" display
and occludes blood measured wounds timely wound healing as
flow improvement in
Objective: and observed intervention. evidenced by:
wound healing as
 Disruption of skin Ⅰ changes.  Minimized
evidenced by:
in her plantar foot presence of
Pressure not relieved  Intact skin or
surface at the  Demonstrated  Maintaining wounds.
minimized
right lower Ⅰ good skin clean, dry skin
presence of  Minimized
extremity hygiene, e.g., provides a barrier
Microthrombi wound. erythema.
wash thoroughly to infection.
 Wound is formation
and pat dry Patting skin dry  Minimized
classified as grade
Ⅰ carefully. instead of rubbing purulent
2 in wagner  Minimize the
reduces risk of discharge.
classification(Dee + occlusion in presence of
dermal trauma to  No fever noted
p ulcer to bone, capilliaries and blood redness or
fragile skin.
ligament or joint. flow erythema.  Identified

 Localized  Minimize the intervention to

Ⅰ  Instructed family  Skin friction
erythema and presence of prevent and
to maintain clean, caused by stiff or

1
 Assessment Nursing Diagnosis Pathophysiology/ Planning Intervention Rationale Evaluation
Scientific
explanation

redness Formation of blister purulent dry clothes, rough clothes reduce infection
discharge. preferably cotton leads to irritation
 Purulent Ⅰ
fabric (any T- of fragile skin and
discharge  identify
Rupture of blister shirt). increases risk for
intervention to
 (+) pain scale= infection.
Ⅰ prevent/reduce
3/10
+ open wound infection.
 Emphasized  Improved
Precipitating importance of nutrition and
and Relieving
factors: The pain adequate nutrition hydration will
worsen when the and fluid intake. improve skin
wound being condition.
touched 
 Demonstrated to

  the family  Providing the

members on how family with
Quality: Achy to make a guava alternative
decoction to solution assists
 
apply to the them in optimal
Radiation: Pain wound as healing with less
in the right lower alternative expensive
leg
disinfectant. resources.

 
 Instructed family  Long and rough
Site and to clip and file nails increase risk

2
 Assessment Nursing Diagnosis Pathophysiology/ Planning Intervention Rationale Evaluation
Scientific
explanation

nails regularly. of skin damage.

Severity:Right
lower leg; pain  Provided and  Wound dressings
scale: 3/10
applied wound protect the wound
Timing and dressings and the
Treatment carefully. surrounding
History: Pain tissues.
started when
patient starting to
move. DEPENDENT:

 Vital signs: Administer Clindamycin

Clindamycin and Hydrocholride
BP 150/90 mmHg
Acetaminophen nhibits protein
Apical 86bpm prescribed by the synthesis in

Temp 38.2 C physician. susceptible

bacteria by binding
Resp 29 cpm
to the 50S subunits
of bacterial
ribosomes and
preventing peptide
bond formation,
which causes
bacterial cells to

3
Assessment Nursing Diagnosis Pathophysiology/ Planning Intervention Rationale Evaluation
Scientific
explanation

die.

Acetaminophen is a
medication used to
relieve pain and
reduce fever.