Francine Nicole P.

Cajoles

BSN III-1

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective: Impaired Tissue After 8 hours of Assess spacious Proper

Integrity related to the nursing intervention and state of the assessment of the
Presence of presence of gangrene patients skin will have wound and the injury and the
gangrene in in the extremities. an improvement and healing process. healing process
the left foot edema will be reduced will assist in
determining the
Presence of next action.
Edema

Treat the wound Taking care of the

wound can keep
the wound free
from
contamination

Administer Administering the

medication as medication will
prescribed lower the blood
sugar levels
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for infection After 8 hours of Observed signs of Patients may be
related to nursing intervention infection and entered with an
Hindi pa rin hyperglycemia patient will identify inflammation. infection.
gumagaling pero hindi interventions to
na naman siya prevent the risk for Improve efforts to Prevents cross
masakit. infection prevention by infection.
good hand
Objective: washing for all
people in contact
FBS 178.61 with patients
including the
Presence of patients
gangrene themselves.

Give your skin Taking care of the

with regular care. wound can keep
the wound free
from
contamination

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Disturbed sleeping After 8 hours of Assess sleep High percentage

patterns related to nursing intervention pattern of sleep
Nahirapan ako dati anxiety and other patient will achieve disturbances that disturbances can
matulog kasi inaalala ko generated awakening optimal amount of are associated affect the
mga anak ko saka nung and excessive sleep. with the recovery of the
nasa baba ako ang hirap stimulation (noise) environment. patient.
matulog kasi mayat
maya may bagong Observed and To determine
pasyente na dinadala. obtain feedback usual sleep
regarding usual pattern and
Objective: bedtime, routines provide
of hours of sleep. appropriate
Restlessness intervention.

Dark circles Provide calm and To help promote

under the eyes quite conducive
environment. atmosphere for
restful sleep.

Ensure To keep
appropriate environment
temperature and conducive for
ventilation sleep