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    Assessment Explanation of The Problems Planning Intervention Rationale Evaluation

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    Pau-pau Basi
    Nursing diagnosis is risk of infection due to degloving injury on the right arm. Short term goals are for the patient to decrease pain complaints after 8 hours, maintain normal temperature after 8 hours, sleep and rest after 8 hours, and verbalize understanding of interventions after 15 minutes. Nursing interventions include wound dressing assessment, vital sign monitoring especially temperature, maintaining clean environment, encouraging proper diet and exercise, and instructing to avoid rubbing or scratching the wound. The evaluation is to reduce infection risk and fasten healing over 4-6 weeks.

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    Assessment Explanation of The Problems Planning Intervention Rationale Evaluation

    Uploaded by

    Pau-pau Basi
    31 views1 page
    Nursing diagnosis is risk of infection due to degloving injury on the right arm. Short term goals are for the patient to decrease pain complaints after 8 hours, maintain normal temperature after 8 hours, sleep and rest after 8 hours, and verbalize understanding of interventions after 15 minutes. Nursing interventions include wound dressing assessment, vital sign monitoring especially temperature, maintaining clean environment, encouraging proper diet and exercise, and instructing to avoid rubbing or scratching the wound. The evaluation is to reduce infection risk and fasten healing over 4-6 weeks.

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    Nursing diagnosis is risk of infection due to degloving injury on the right arm. Short term goals are for the patient to decrease pain complaints after 8 hours, maintain normal temperature after 8 hours, sleep and rest after 8 hours, and verbalize understanding of interventions after 15 minutes. Nursing interventions include wound dressing assessment, vital sign monitoring especially temperature, maintaining clean environment, encouraging proper diet and exercise, and instructing to avoid rubbing or scratching the wound. The evaluation is to reduce infection risk and fasten healing over 4-6 weeks.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    31 views1 page

    Assessment Explanation of The Problems Planning Intervention Rationale Evaluation

    Uploaded by

    Pau-pau Basi
    Nursing diagnosis is risk of infection due to degloving injury on the right arm. Short term goals are for the patient to decrease pain complaints after 8 hours, maintain normal temperature after 8 hours, sleep and rest after 8 hours, and verbalize understanding of interventions after 15 minutes. Nursing interventions include wound dressing assessment, vital sign monitoring especially temperature, maintaining clean environment, encouraging proper diet and exercise, and instructing to avoid rubbing or scratching the wound. The evaluation is to reduce infection risk and fasten healing over 4-6 weeks.

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    © All Rights Reserved
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    Download as docx, pdf, or txt
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    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.

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