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Assessment Diagnosis Planning Intervention Rationale Evaluation

The patient, Elena Antonio, is a 70-year-old woman with impaired skin integrity manifested by wounds and bruises on her legs and arms. She has difficulty walking and uncontrolled movements during hypoglycemic reactions. The nurse established rapport, provided wound care and insulin injections, ensured optimal nutrition, and maintained a safe environment to promote timely wound healing and physical well-being without complications.

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Jhoizel Venus
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275 views4 pages

Assessment Diagnosis Planning Intervention Rationale Evaluation

The patient, Elena Antonio, is a 70-year-old woman with impaired skin integrity manifested by wounds and bruises on her legs and arms. She has difficulty walking and uncontrolled movements during hypoglycemic reactions. The nurse established rapport, provided wound care and insulin injections, ensured optimal nutrition, and maintained a safe environment to promote timely wound healing and physical well-being without complications.

Uploaded by

Jhoizel Venus
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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ASSESSMENT

DIAGNOSIS

PLANNING After nursing intervention, the patient will be able to: 1. Display timely wound healing of wounds and bruises without any complications. 2. Maintain optimal nutrition/physica l well-being. 3. Verbalize understanding of causative factors 4. Shows concern on physical wellbeing.

INTERVENTION 1. Identify underlying condition involved. 2. Note general debilitation, reduced mobility, changes in skin/muscle mass associated with aging

RATIONALE 1. To know what could be the possible cause of present condition. 2. To discern whether mobility and/or other physiological factors influences having impaired skin integrity 3. To serve as baseline data for future comparisons

EVALUATION After nursing intervention, the patient was able to: 1. Display timely wound healing of wounds and bruises without any complications. 2. Maintain optimal nutrition/physica l well-being. 3. Verbalize understanding of causative factors 4. Shows concern on physical wellbeing.

SUBJECTIVE: IMPAIRED SKIN Madalas akong INTEGRITY related to magkasugat, as injury trauma as verbalized by the manifested by patient. wounds and bruises found at both left OBJECTIVE: and right legs and (+) wounds at both left arm and use of and right legs defective wheel (+) bruises at both left chair and right arms Inability to walk/stand alone Uncontrolled/jerking movements during hypoglycemic reactions Use of defective wheelchair

3. Determine size, shape, consistency and texture of wounds. 4. Note presence of 4. Skin is a compromised particularly vision, hearing or important speech. avenue of communication for these people and when compromised, may affect responses. 5. Inspect skin on a 5. To see if daily basis, improvement is describing observed with wounds and regards to the

bruises and wounds and changes bruises. observed 6. Keep the area 6. To assist bodys clean/dry, natural process carefully dress of repair. wounds, prevent infection and stimulate circulation to surrounding areas 7. Limit/avoid use 7. Moisture of plastic potentiates skin material. breakdown. Remove wet/wrinkled linens promptly. 8. Provide optimum 8. To provide a nutrition and positive nitrogen increased balance to aid in protein intake. healing and to maintain general good health 9. Assist patient in 9. Enhances understanding commitment to and following a plan, optimizing program of outcomes. preventive care. 10. Assist patient to 10. To control learn stress feelings of reduction and helplessness and alternate therapy deal with techniques situations.

Name of Patient: Elena Antonio DATA: Received patient awake sitting on the wheel chair Conscious and coherent Has taken a bath With new and clean diaper worn (+) redness on sacral area (+) wounds at both left and right legs (+) bruises at both left and right arms Drying of lips Dry skin on the forehead, arms and legs

Age: 70 years old

ACTION: Established rapport Assisted in her breakfast (rice porridge and a cup of milo) Blood glucose monitoring rendered and recorded Given a shot of insulin injection Due medications for morning given Wound care rendered Vital signs taken and recorded Stipulated a conducive atmosphere Bed side care rendered Conducive environment maintained Safety measures observed

Patient transferred from dining area to bed room Moved patient from wheel chair to bed Assisted in her lunch (menudo, cup of rice and a cup of water) Due medications for afternoon given Had the patient sleep for afternoon nap RESPONSE: For continuity of care Endorsed

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