Columban College, Inc.
College of Nursing
ASSESSMENT
DIAGNOSIS
PLANNING
SUBJECTIVE:
“Nilagyan naming
ng toothpaste
yung sugat para
hindi lumala” as
verbalized by the
patient’s mother.
Inability to
provide
adequate care
to the sick,
disabled,
dependent, or
vulnerable/atrisk family
member.
SHORT TERM
GOAL:
OBJECTIVE
- Presence
of
toothpaste
covering
the area
After 1 hour
of nursing
intervention,
the patient’s
mother will
be able to
demonstrate
proper
wound/burn
management.
LONG TERM
GOAL:
After 2 hours
of nursing
intervention,
the patient’s
mother was
able to
perform
necessary
procedure
correctly and
to be able to
explain
reason for its
action
INTERVENTION
1. Introduce
yourself to
the patient
and the
patient’s
mother.
2. Gather all
needed
materials.
3. Demonstrate
how to
properly
irrigate the
wound.
4. Demonstrate
the proper
wound
cleaning.
5. Demonstrate
the proper
application
of the
medication.
6. Demonstrate
how to dress
the wound
properly.
Reference –
15th edition
of NANDA
book, pages
524-528.
Prepared by:___________________________________________________
by:______________________________________
Student Nurse
Clinical Instructor
RATIONALE
EVALUATION
1. Establish
rapport to
the patient
and to
patient’s
mother.
2. To help
with the
efficiency
of the
procedure
3. It
promotes
healing by
removing
tissue and
other
foreign
bodies
that can
impede
healing
process.
4. It
decreases
the
potential
healing for
risk.
5. It
decreases
the risk of
infection.
6. It prevents
bacteria
with
effective
wound
care.
SHORT
TERM:
After 1 hour
of nursing
intervention,
the patient’s
mother was
able to
demonstrate
the proper
wound/burn
management.
LONG TERM:
After 2 hours
of nursing
intervention
the patient’s
mother was
able to
perform
necessary
procedure
correctly and
to be able to
explain
reason for its
action.
Noted