Date

and
time
Cues Need Nsg. Diagnosis Objectives of care Nsg. ntervention Evaluation
J
U
L
Y

17,

2
0
1
1

@

7
3


S
H

F
T

" nasamad lage
akong mata
ganinang buntag
kay na tumba ko. Na
walaan ko'g kusog

As verbalize by the
patient.

Objective:

-with skin laceration
on the right upper
eye area.

-with redness on the
wound site.

-with small amount
of blood on the
wound.



Vital signs:

T-36
BP-130/90
CR-69
PR-69
RR-24

H
E
A
L
T
H

M
A

N
T
E
N
A
N
C
E

P
A
T
T
E
R
N
Risk for infection
related to breakage
of superficial skin.


ntegumentary
system is the first line
of defence against
infection and other
microorganisms.
Breakage of it will
result an opening
thus result to entry of
microorganisms.
After 3 hours span
of care, patient will
be able to be free
from infection as
evidence by:

a. Free from
redness; and

b. Absence of
bleeding.
1. Maintain asepsis
and wound care.

Use of aseptic
technique
decreases the
chances of
transmitting or
spreading
pathogens to the
patient.

2. Encourage patient
to avoid touching
the wound.

to prevent
contamination and
prevent infections.


3. Encourage intake
of protein and
calorie-rich foods

this maintains
optimum nutritional
status.


4. Give antibiotic
drug as ordered.

" Goal Met

After hours span
of care patient
had able to have
free from
infections as
evidence by:

a. No more
redness;
and
b. No more
bleeding.
antibiotics
serves as
prophylaxis to
prevent infection.

5. Encourage the
patient to have or
maintain good
hygiene.

Good hygiene
reduces the risk of
having infections.