"Impa|red sk|n |ntegr|ty"

Assessment |ann|ng Intervent|on kat|ona|e Lva|uat|on

Sub[ecLlve
O 'Kumikirot
yung sugat
ko as
ver ba l i z e d by
t he patient

Cb[ecLlve
O i sr upt ion o I
ski n
s u r I a c e a t
t h e l e I t
b r e a s t
O !ain


O Iter 3 days
nursing
intervention,t
he client will
be able to
display
improvement
in wound
healing as
evidenced
by:
Intact skin
or minimized
presence oI
wound.
bsence oI
redness or
erythema.
bsence
oI purulent
discharge.
bsence
oI itchines

O ssessed skin.
Noted color,
turgor, and
sensation.
escribed and
measured
wounds and
observed
changes.
O emonstrated
good skin
hygiene,
e.g.,wash
thoroughly and
pat dry careIully.
O Instructed Iamily
to maintain clean,
dry clothes,
preIerably cotton
Iabric

O stablishes
comparative
baseline
providing
opportunity
Ior timely
intervention.
O aintaining
clean, dry skin
provides a
barrier to
inIection.
!atting skin dry
instead oI
rubbing reduces
risk oI dermal
trauma to
Iragile skin.
O $kin Iriction
caused by stiII
or rough
clothes leads to
irritation oI
Iragile skin and
increases risk
Ior inIection

O t the end oI the 3 days
nursing intervention, the
client was able to
display improvement in
wound healing as
evidenced by:

O inimized presence oI
wounds.

O $everal wound shave
dried up.

O inimized erythema.

O inimized purulent
discharge.