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SAINT LOUIS UNIVERSITY

SCHOOL OF NURSING
Bonifacio Street, Baguio City

Nursing Care Plan

Submitted to:
Mrs. Sharon Hogat

Submitted by:
Balanay, Sonia Marie L.
F. NCP PROPER

CUES EXPLANATION OF GOALS AND INTERVENTIONS RATIONALE EVALUATION ACTUAL


THE PROBLEM OBJECTIVES CRITERIA EVALUATION
Subjective: Situation analysis: STO: Dx: Fully met:
 “Medyo Malaki Impaired skin After 8 hours of  Vital signs assessed  To establish baseline The client will
yung hiwa sa integrity was due to nursing and recorded data. properly
batok ko, the client tissue interventions, the demonstrate health
malaki na kasi trauma on the surgical patient will be  Inspect the incision  Frequent assessment teaching given and
yung mass”. incision site from his able to: every shift using can detect early with a score of 3/3
 “Hindi naman recent surgery caused 1. Demonstrate REEDA (redness, signs and symptoms of the goals of
masakit yung by liposarcoma on nape proper way of edema, ecchymosis, of infection. LTO such as
sugat, pero region. wound care discharge, and maintain the
nagiingat lang and proper approximation) wound intact, to
ako sa dressing. shows sign of
paggalaw ko sa Health Implication: Tx: wound healing and
bandang batok The skin is a barrier to 2. Understand  Administered  To interfere with no sign of redness
ko”. infectious agents, the importance medications like bacterial cell wall around the incision
however, any break in of caring the Sulbactam - synthesis and to treat site.
Objective: the skin can readily incision site. ampicillin. occurrence of
 Disruption of serve as a portal of infection. Partially met:
skin surface at entry putting the LTO . The client will
the nape region. individual at risk for After 3-4 days of  Carefully dress  To prevent infection. properly
 Wound is potential infections. nursing wounds demonstrate health
approximately (Fundamentals of interventions, the  Use appropriate  To protect wound teaching given and
3-4 inches in Nursing by Kozier, et. patient will be barrier dressings, with the score of
and or the
length. al.,7th edition, page able: wound coverings, 2/3 of the goals of
 With intact and 633) 1. Maintain the drainage appliance surrounding area. LTO such as
patent JP drain wound intact. and skin protective maintain the
draining to agents for open wound intact and
bloody 2. Shows sign of wounds. no sign of redness
discharges. wound healing around the incision
 With initial (dry & intact site.
vital signs of:
BP= 160/100mmhg wound and Ed: Not met:
PR= 72 bpm initial scaring)  Encourage to The client will not
 To provide a
RR= 20 cpm increase diet rich in properly
T= 36.3 C 3. No redness Vitamin C and E. positive nitrogen demonstrate health
SpO2= 95% around the teaching given and
balance to aid in
incision site. with the score of
Nursing skin/tissue healing 0/3 of the goals of
Diagnosis: LTO.
and maintain general
Impaired skin
integrity related to good health.
tissue trauma
secondary to status  Encourage early  To promote
post excision of ambulation or
nape mass. circulation and
mobilization.
reduces risks
associate with
immobility.
 Encourage to  To promote wound
increase protein healing.
intake.
 Instruct patient to  Splinting provides
use a pillow for
splinting the support to the area,
incision site when minimizing
moving.
discomfort and
encouraging the
patient to move or
cough.
 Instructed to keep  Moistures harbors
the dressing clean
bacteria and
and dry.
pathogen

 Taught on proper  To prevent infection.


hand washing
before changing the
dressing or
touching the
wound.

RERERENCES:

StudyLib. (2018). Impaired skin integrity related to tissue trauma. Priority Nursing Diagnosis. Retrieved from http://studylib.net/doc/6976670/priority-nursing-
diagnosis-impaired-skin-integrity-r-t-im.

Impaired Skin Integrity: Nursing Diagnosis & Care Plan. (2017, October 06). Retrieved from https://nurselab.com/impaired-skin-integrity/.