Asqsessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Short term INDEPENDENT:  By the end of nursing

Data Disturbed goal  care the patient was
body image  -Establish  able to
Reports related to After 12 rapport  To
weight gain, change in hours of with the incorporate  Verbalize an
easy appearance nursing patient- trust in all understanding
bruising, and intervention Assess the procedures of bod
edema of his the patient client’s to be done. changes
feet, lower will be able coping  -  recognize and
legs and to maintain mechanism.  incorporate
hands the bp of  Assess for  body image
120/80 any  change into
Objective changes in  To check how self concept in
data Long term personal patient cope an accurate
goal appearance up with the manner
Physical caused by situation. without
examination After 3 days the  negating self
BP 150/110 of nursing cortisol  esteem
2t edema of intervention excess.   verbalize
lower the patient  Assess  relief of
extremities will be able patient’s  anxiety and
puplish to feel feelings  To note and adaptation to
striae on better and about report to the actual/altered
abdomen, have a self their attending body image
thin esteem changed physician.  seek
extremities appearance And do information
with thin and coping nursing and actively
friable skin. mechanism. intervention. pursue
Sever acne  Reassure  growth
of the face the  -Goal met
and neck patient  -To know if
that the there’s
physical withdrawal
changes from social
are result interaction.-
of the To help
elevated patient
hormone develop
levels and realistic
most will expectations
resolve about the
when change in
those levels physical
return to appearance.
normal. 
 Encourage 
the 
patient to  -To enhance
verbalize patient’s
feelings coping
about the strategies.
body image 
change 
 Promote 
and 
atmosphere  -To support
of the patient’s
acceptance adjustments
and positive to his or her
caring appearance
 
Dependent 

 Administer 
medication 
as indicated 
by the  -To check and
physician. know the
 Follow and health status
do the of the
laboratory patient.
exams and  -To provide
tests as social
indicated support and
by the offer coping
physician strategies
that have
Collaborative proven
successful
Refer to local
support groups

Assessmen Diagnosi Planning Intervention Rationale Evaluation

t s
Subjective Impaired Short term INDEPENDENT By the end of nursing
Data skin goal To incorporate trust care the patient was
integrity  Establish rapport in all procedures to able to
easy related After 12 with thepatient be done.
bruising, to hours of of  display
and edema edema, nursing  Obtain history To assess and have a timely
of his feet, impaired interventio of baseline on the healing of
lower legs healing n the condition,includin treatment that skin lesions,
and hands and thin patient will g age at onset, should be done. wounds, or
and be original site or pressure
Objective friable characteristics of sores
Data skin lesions, duration without
of problem, and To check for complication
edema of changes that dehydration and s
lower have occurred monitor condition  maintain
extremities overtime. optimal
puplish  Note skin color, nutrition and
striae on texture, and -To check for physical
abdomen, turgor. Assess infection and know well-being
thin areas of least necessary  -participate
extremities pigmentation for intervention. in
with thin color changes prevention
friable skin  Inspect skin on measures
daily basis, -To monitor the and
describing condition of the treatment
wound or lesion wounds and plan for program.-
characteristics appropriate care.  verbalize
and changes feelings of
observed. To assist body’s increased
 Keep the area natural process of self-esteem
clean and dry, repair.-To protect the and ability to
carefully dress wound and/or manage
wounds, manage surrounding tissues situation. –
incontinence, and 
stimulate Goal met
circulation to
surrounding
areas.
 Use appropriate
barrier dressings,
wound coverings,
drainage
appliances,
vacuum assisted
closure device
and skin-
protective agents
for open, draining
wounds and
stomas

Dependent  To help in the

wound
Administer medications, healing and
asindicated by the to prevent
physician. infection

COLLABORATIVE

Consult with wound 
specialist, as indicated. 

Assist with 
debridement or 
enzymatic therapy, as 
indicated 

 To assist with
developing
plan of care
for
problematic
or potentially
problematic
wounds.

 To remove
nonviable,
contaminate
d, or infected
tissue