NursingDiagnosisBackground StudyINFERENCEGoals andObjectivesInterventions Rationale Evaluation
ImpairedSkin/TissueIntegrityrelated tomechanicaltrauma of surgicalremoval of skin andsubcutaneous tissuesecondary toCesareansection
“Mayda aksamad kaygin Cesareanak paganak,”verbalized bythe client.
Destructionof skin layersDesruption of tissue layers.(+)Rednesson theincision site.(+)Swellingon theincision siteSkin is thebody’s firstline of defenseagainstforeignmaterialsthat can beconsideredas injuringagents.Once theskin isdisrupted,this will puta person atrisk since itmaybecome agoodmedium forbacterialgrowth.Cesareansection,like anyothersurgicalprocedures, includesinvasion of the insidebody,specificallyEmergency CSAbdominal incisionandUterineincisionAlterations of theSkin
After 3 days of nursinginterventions, thepatient will be ableto display timelyhealing of skinlesions/ woundswithoutcomplication.
:After 8 hours of nursinginterventions, thepatient will be ableto:
Establish rapportPerform bedsidecareInspect skin ondaily basis andobseve forchanges andunusualitiesKeep the areaclean, carefullydress wound,support incison,prevent infection To gain trustwith the client To enhancepatient’s self esteem and toprovidecomfort to thepatient To determineunusual tiesand report itto physicianfor prompttreatment. This will assistbody’s naturalprocess of Goal met asevidencedby thepatient hasable todisplaytimelyhealing of skin lesions/woundswithoutcomplication.