Welcome to Scribd. Sign in or start your free trial to enjoy unlimited e-books, audiobooks & documents.Find out more
Download
Standard view
Full view
of .
Look up keyword
Like this
216Activity
0 of .
Results for:
No results containing your search query
P. 1
Impaired Skin Integrity

Impaired Skin Integrity

Ratings:

5.0

(1)
|Views: 20,251|Likes:
Published by prickybiik

More info:

Published by: prickybiik on Mar 23, 2010
Copyright:Attribution Non-commercial

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as DOCX, PDF, TXT or read online from Scribd
See more
See less

09/26/2013

pdf

text

original

 
 
Cues NursingDiagnosisRationale Objectives InterventionsRationale EvaluationSubjective:
³Medyomalaki ngayung hiwana ginawasa tiyan ko,nasa5inches dinkaya bakamatagalanangpaghilomng sugatko.´ As thepatientverbalizeda days after thesurgery.Impaired skinintegrityrelated tosurgicalincision onthe RightUpper Quadrant of the abdomenas evidencewith
Subjective:
³Medyomalaki ngayung hiwana ginawasa tiyanko, nasaSurgicalIntervention(Cholecystectomy)Incision on theRight upper quadrant toremove thedisease tissue(Surgicaldressing on theright upper quadrant of her abdomen)Surgery involvescutting/penetration of skin surface and
Short term:
 After 20-30 minutesof nursingintervention, thepatient will be ableto:1. DemonstrateProper way of wound careand proper dressing2. Understandtheimportance of caring theincision site
Independent:
Keep thearea cleanand dry
Provide asplintingpillow
Moistur esharborsbacteriaandpathogen
Splintingprovidessupportto thearea ,minimizing
Short term:
 After 30 minutes of nursing intervention,the patient was ableto:1. Demonstrateproper way of wound careand proper dressing
 
G
OAL FULLYMET
2. Understandtheimportance of caring theincision site asshe verbalized³Iniingatan ko ang
 
 
F
eb, 17,2010.
Objective:
y
Surgicaldressingon therightupper quadrantof her abdomen
y
Rednesson theskinsurrounding theincisionsight
y
Disruption of the5inchesdin kayabakamatagalanangpaghilomng sugatko.´ As thepatientverbalizeda daysafter thesurgery.
F
eb, 17,2010.
Objective:
y
Surgicaldressingon theright upper quadrantskin layersInjury or traumaon the skin/tissue is inflictedBecause of theinjury there invasodilatation tohurriedly sendthe nutrients inthe body viabloodstream(Redness onthe skinsurroundingthe incisionsight)Because of vasodilatationthere is redness
Long term:
 After 3-4 days of nursing intervention,the patient will beable to:1. Maintain thewound intact.2. Shows sign of 
InspecttheincisioneveryshiftusingREEDA(redness,edema,discomf ort andencouraging thepatientto moveandcough
 
F
requentassessmentcandetectearlysignsandsugat ko na wagmaimpeksyon.´
 
G
OAL FULLYMETLong term:
 After 4 days of nursingintervention, thepatient was able to:1. Maintained thewound intact asverbalized ³Dina gaanungmasakit yungsugat ko.´
 
G
OALPARTIALLY MET
2. Shows dry and
 
 
skinsurface(epidermis)
y
Injury onthe skinlayers(dermis)of her abdomen
y
Rednesson the skinsurrounding theincisionsight
y
Disruptionof the skinsurface(epidermis)
y
Injury onthe skinlayers(dermis)on thesurroundingtissue on theinjury site
Reference:
Principles of Med-Surg Vol. 14
th
edition byLemone andBurke
 
wound healing(dry and intactwound andinitial scaring)3. No redness onthesurroundingarea.ecchymosis,discharge, andapproximation)
Carefullydresswounds
Informpatient of thepurpose of self-carepractices
Useappropriatsymptoms of infection
Topreventinfection to
Toincreasecompliance
Toprotectintact woundand initialscaring
 
G
OALPARTIALLYMET
3. No redness onthe surroundingarea.
 
G
OALPARTIALLYMET

Activity (216)

You've already reviewed this. Edit your review.
1 hundred reads
1 thousand reads
Charlene Tomas liked this
leslie_macasaet liked this
jessica_ramos_73 liked this

You're Reading a Free Preview

Download
scribd
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->