Nursing Analysis Goal / Nursing Rationale Evaluation

Problem Objectives Interventions

Cues
Impaired skin Situation Goal: The client
integrity analysis: By the end of developed and
related to Impaired skin the shift, the maintained
post surgery integrity was client will optimal
of the due to the develop and conditions for
abdomen as client’s tissue maintain wound healing
evidenced by trauma on the optimal as evidenced by
sutures in the surgical incision conditions for responses to
abdominal site from his wound healing. interventions
area. recent surgery 1. Note skin -To document and teaching
caused by small Objectives: color, texture, status and and actions
O>-disruption bowel 1. After 30 and turgor. provide performed and
of skin surface obstruction. minutes, the 2. Palpate skin baseline for gradual healing
-destruction nurse will be lesions for size, future of his wound.
f skin layers Health able to assess shape, comparisons.
Implication: the extent of consistency, NANDA 11th Edi.
The skin is a involvement or texture, p. 620-621
barrier to injury. temperature,
infectious and hydration.
agents; 3. Determine
however, any degree or depth
break in the of injury or
skin can readily damage to skin.
serve as a 4. Measure
portal of entry length, width,
putting the depth of wound.
individual at 5. Inspect
risk for surrounding
potential skin for
infections. erythema,
(Fundamentals induration, and
of Nursing by maceration.
Kozier, et.al., 7th 6. Note odors
edition, page emitted from
633) 2. After the the wound.
shift, the nurse 1. Inspect skin,
will be able to describing
assist the client wound -To monitor
with correcting characteristics progress of
and minimizing and changes wound healing.
condition and observed. NANDA 11th Edi.
promote 2. Remeasure p. 621
optimal healing wound and -To protect the
of wound. observe for wound and
complications. surrounding
tissues. NANDA
11th Edi. p. 622
3. Use -Promotes
appropriate circulation and
dressings, reduces risks
wound associated with
coverings, immobility.
drainage NANDA 11th Edi.
appliances for p. 622
open or
draining
wounds.
4. Encourage
early
ambulation.