ASSESSMENT NSG DX INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Impaired skin -3 Days after -Assess skin -able to Goal Met after
“kaka opera integrity r/t patient should compare the 3 days.
lang sa akin 5 surgery be able to -note the color differences Nursing
days ago.” As improve on from the intervention
verbalized by wound healing -observe baseline data. display
the patient. AEB changes of the improvement
wound. in would
-Absences of healing AEB;
itchiness -skin hygiene -Maintaining
wound -wounds have
-Absence of hygiene care dried
redness can provide
Objective: barrier to -no more
(+) pain -reduce pain infection redness
Pain scale of to 4 out of 10.
7/10 -instruct patients -to gain -reduced pain
-absence of family how to knowledge of from 7 to 4 out
(+) suture of blood properly clean prevention of 10.
left lower discharge wound. from infection
extremities -absence of
-pat the wound -reduce itchiness.
(+) redness when cleaning rubbing avoid
instead of skin trauma.
(+) blood rubbing.
discharge