Assessment Explanation of the Planning intervention Rationale Evaluation

problems

Nursing Diagnosis: Risk for infection-

Risk for infection Related
to alteration in skin
integrity secondary to
degloving injury
Subjective Data:
“May sugat yung right arm
ko”
Objective Data:
>With Type 1 Diabetes
mellitus
>Presence of fluid on the
wound dressing
>Degloving injury @ right
hand
>T-36.3°C
Vulnerable to invasions
and multiplications of
pathogenic organisms
which may compromise
health.
Degloving, also called
avulsion, is a type of
severe injury that happens
when the top layers of your
skin and tissue are ripped
from the underlying
muscle, connective
tissue, or bone. It can
affect any body part, but
it’s more common in the
legs. Degloving injuries
are often
life-threatening. This is
because they involve large
amounts of blood loss and
tissue death.
STO> After 8 hours of
STO> Within 8 hours  Assess Wound  To know what nursing
nursing intervention, the
of effective nursing dressing. intervention is patient was free from any
interventions, the
appropriate for the signs of infections as
patient will be free from evidenced by normal body
any signs of infection patient.
temperature
 Assess vital sign  Fever may indicate
specially temperature. infection and It
confirms the
LTO> Within 3 days of effectiveness of LTO> After 3 days of
nursing intervention,
treatment that is nursing intervention, the
patient will achieve patient’s wound is slowly
timely wound healing and performed.
healing as evidenced by
be free from hemorrhagic  Keep a sterile minimal discharges on the
discharge on the wound
dressing technique  To reduce risk for wound site
site
during wound care. infection.
 Maintain Clean
environment  To minimize microbes
that can infect the
 Encouraged to eat
appropriate food to wound.
health condition  To fasten wound
such as: green leafy healing.
foods and fruits

 Instructed to do deep
breathing exercise
 It can help the body
 Advice to avoid to relax that can
rubbing and decrease pain
scratching. Provide severity.
gloves or clip the  Rubbing and
nails if necessary. scratching can cause
further injury and
delay healing.