Problem Nursing Background Goal and Nursing Intervention Rationale Evaluation

Diagnosis Knowledge Objectives

Open High risk for Trauma on skin After 2 hours of Independent After 2 hours of
wound infection d/t at left anterior nursing 1. Establish ➢ To gain trust nursing intervention
inadequate intervention the rappoirt and the patient will be
patient will gain
primary knowledge in cooperation able to gain
defense as Broken skin infection control of the knowledge in
manifested by as evidenced by patient infection control as
broken skin discussing the 2. Teach patient ➢ Hand evidenced by his
Open wound wound care. to wash hands washing discussion in wound
often, reduces the care. Therefore, the
especially
risks for goal was met
before
Risk for toileting, infection
infection before meals
and before and
after
administering
self-care
3. Discuss to
➢ To impart to
patients the
following signs the patient
of infection - when the
redness, wound
swelling, become
increased pain,
infected and
or purulent
drainage on the when to
site and fever sought
medical
care
4. Demonstrate
➢ To know if
and allow
return the patient
demonstration really
of wound care understand
the principle
of proper
wound care