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Assessment Explanation of the Planning intervention Rationale Evaluation


Nursing Diagnosis: Risk for infection-

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