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ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Impaired Skin At the end of the >Recommended >To reduce risk of Goal met. The patient
“Kumakalat ang Integrity r/t alteration shift, the patient will keeping nails short. dermal injury when was able to
rashes sa balat ko” as in skin appearance as be able to severe itching is demonstrate
verbalized by the manifested by demonstrate >Kept the area present behaviours/
patient presence of rashes behaviours/ affected clean and dry techniques to prevent
Objective” techniques to prevent >To prevent further skin breakdown.
>presence of rashes skin breakdown >Removed wet/ invasion of
>frequent scratching wrinkled linens microorganism
>disruption of skin
surface >Instructed patient >Moisture potentiates
not to use tight skin breakdown
clothings
>To prevent skin
>Administered irritation
triderm as ordered.
>To decrease irritable
itching

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