CUES NURSING DIAGNOSIS RATIONALE GOAL INTERVENTIONS RATIONALE EVALUATION

Independent
Subjective: Impaired skin integrity related Physical immobility After 2-3 hours of - Ascertain attitudes of - Identifies areas to be After 2-3 hours of
- “Ang dami ko to prolonged immobility as nursing interventions, individual/SO(s) about addressed in teaching plan and nursing interventions,
na sugat” as evidenced by clients Pressure on soft the client will be able condition. potential referral needs. (Nurses the client was able to
verbalized by verbalization, “Ang dami ko na tissues between bony to participate in pocket guide, 9thed, Doenges, participate in
the client. sugat”; and associated with dry prominences prevention measures Moohouse, Murr, p.463) prevention measures
skin, disruption of skin ↓ and treatment - Inspect skin in daily basis, and treatment program.
surface(epidermis) and (+) skin Compresses program. describing lesions and changes
Objective:
lesions. capillaries & observed. - To monitor progress of wound Goal met.
- dry skin healing. (,p.463)
- disruption of occludes blood flow
skin surface ↓ - Keep the area clean/dry,
(epidermis) Pressure not relieved carefully dress wounds, support
- (+) skin ↓ incision - To assist body’s natural process of
lesions Microthrombi repair (,p.463)
formation
↓ - Use appropriate barrier dressing,
Vital Signs: wound coverings, and skin-
+ occlusion in
BP – 110 / 70
capillaries & blood protective agents - To protect wound and surrounding
mmHG tissue. (,p.463)
T - 36.5° C flow
↓ - Avoid use of plastic material and
RR -20 cpm remove wet linens promptly
PR – 90bpm Disruption of skin
↓ - Moisture potentiates skin breakdown
Skin lesions - Encourage early ambulation (,p.463)
↓
Dependent
+ open wound - Promotes circulation and reduces
↓ - Assist the client/ SO(s) in risks associated with immobility
Impaired skin understanding; ff medical (,p.463)
integrity regimen and developing program
of preventive care & daily - Enhances commitment to plan,
maintenance optimizing outcomes (,p.464)

Collaborative
- Consult with wound specialist - To assist in developing plan of care
Reference: for problematic or potentially serious
- Obtain specimen from draining wounds (,p.464)
Medical- wounds when appropriate for
Surgical culture sensitivities and gram - To determine appropriate therapy
NursingClini staining.
(,p.464)
cal - Assist client to learn stress
Managemen reduction and alternate therapy
t for Positive techniques
- To control feelings of helplessness
Outcomes and deal with situation (,p.464)
Vol II, 8th
edition by
Joyce M.
Black