ASSESSMENT

SUBJECTIVE DATA: May mga sugat ako sa kanang paa. (I have wounds at my right foot.) as verbalized by the client. OBJECTIVE DATA: Disruption of skin surface at the right lower extremity. Wound is about 5mm in diameter. Localized erythema Purulent discharge (+) pruritus on thesite of the wound (+) pain

DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Impaired skin integrity related to inflammatory response secondary to infection.

Risk for infection is Following a 3-day the state in which an nursing intervention, individual is at risk to the client will be be invaded by an able to display opportunistic or improvement in pathogenic agent wound healing as (virus, fungus, evidenced by: bacteria, protozoa, or other parasite) Intact skin or from endogenous or minimized exogenous sources. presence of wound. Wound is less than 5mm in diameter. Absence of redness or erythema. Absence of purulent discharge. Absence of itchiness.

1. Assessed skin. Establishes Noted color, comparative turgor, and baseline providing sensation. opportunity for Described and timely measured wounds intervention. and observed changes. 2. Demonstrated good skin hygiene, e.g., wash thoroughly and pat dry carefully.

At the end of the 3-day nursing intervention, the client was able to display improvement in wound healing as evidenced by: Minimized presence of wounds.

Maintaining clean, dry skin provides a Several wounds have dried up. barrier to infection. Patting skin dry instead of Minimized erythema. rubbing reduces risk of dermal Minimized purulent trauma to fragile discharge. skin. Wounds are still at least 5mm in diameter. (Continue cleaning the wound with disinfectant).

3. Instructed family Skin friction to maintain caused by stiff or clean, dry rough clothes clothes, leads to irritation preferably of fragile skin and cotton fabric (any increases risk for T-shirt). infection.

Presence of itchiness, instructing client to avoid scratching the wound. 4. Emphasized Improved nutrition importance of and hydration will adequate improve skin nutrition and fluid condition. intake.

5. Demonstrated to Providing family the family with alternative members on how solution assist to make a guava them in optimal decoction to apply healing with less to the wound as expensive alternative resources. disinfectant. 6. Instructed family to clip and file nails regularly. 7. Provided and applied wound dressings carefully. Long and rough nails increase risk of skin damage. Wound dressings protect the wound and the surrounding tissues.

ASSESSMENT
SUBJECTIVE DATA: Wala na akong ganang kumain simula ng mamatay ang asawa ko. (I do
not feel like eating since the day my wife died.) as verbalized

DIAGNOSIS

INFERENCE

PLANNING
SHORT TERM:

INTERVENTION
INDEPENDENT:

RATIONALE

EVALUATION

Potential alteration in nutrition: less than body requirements related to loss of appetite.

by the client. OBJECTIVE DATA: Loss of weight Pale conjunctiva and mucous membranes Poor muscle tone Poor skin turgor Weakness Electrolyte imbalances

Intake of nutrients insufficient to meet metabolic needs. A decreased appetite is when you have a reduced desire to eat. Sadness, grief, and anxiety are a common cause of weight loss.

Client will gain 2 pounds per week for the next 3 weeks.

LONG TERM: Client will exhibit no signs or symptoms of malnutrition by time of discharge from treatment (e.g., electrolytes and blood counts will be within normal limits; a steady weight gain will be demonstrated; constipation will be corrected; client will exhibit increased energy in participation in activities).

1. Explain the Client may have importance of inadequate or adequate inaccurate nutrition and fluid knowledge intake. regarding the contribution of good nutrition to overall wellness. 2. Keep strict This information is documentation of necessary to make intake, output, an accurate and calorie count. nutritional assessment and maintain client safety.

Client has shown a slow, progressive weight gain during hospitalization. Vital signs, blood pressure, and laboratory serum studies are within normal limits.

Client is able to verbalize importance of adequate 3. Weigh client daily. Weight loss or gain nutrition and is important fluid intake. assessment information. 4. Ensure that client Large amounts of receives small, food may be frequent feedings, objectionable, or including a even intolerable, bedtime snack, to the client. rather than three larger meals. 5. If appropriate, ask Client is more likely family members to eat foods that or significant he or she others to bring in particularly enjoys. special foods that client particularly enjoys.

6. Stay with client during meals.

To assist as needed and to offer support and encouragement.

COLLABORATIVE: 1. Determine clients Client is more likes and dislikes if likely to eat foods not that he or she contraindicated, particularly enjoys. and collaborate with dietitian to provide favorite foods. 2. In collaboration with dietitian, determine number of calories required to provide adequate nutrition and realistic (according to body structure and height) weight gain. This information is necessary to make an accurate nutritional program for the client.

3. Monitor Laboratory values laboratory values, provide objective and report data regarding significant nutritional status. changes to physician.

4. Administer For the vitamin and c l i e n t t o be mineral aware of the supplements and needed nutrients stool softeners or by his body to bulk extenders, as nourish himself. ordered by Also, giving physician. sources of these nutrients helps the client to easier familiarize himself as to what foods he may include in his diet. 5. To prevent constipation, ensure that diet includes foods high in fiber content. Encourage client to increase fluid consumption and physical exercise to promote normal bowel functioning. Depressed clients are particularly vulnerable to constipation because of psychomotor retardation. Constipation is also a common side effect of many antidepressant medications.

Stenneli G. Trojillo