ASSESSMENT
THE PROBLEM
:Subjective
write something in "
TAGALOG ," as
verbalized by the
.patient
:Objective
Destruction of skin -
layers Disruption of tissue
.layers
Redness on the )+( -
..incision site
Swelling on the )+( -
.incision site
:Nursing Diagnosis
Impaired
Skin/Tissue Integrity
related to mechanical
trauma of surgical
removal of skin and
subcutaneous tissue
secondary to ectopic
.pregnancy
EXPLANATION OF PLANNING INTERVENTION RATIONALE EVALUATION
:DX
Skin is body's first line :STO .Established report - To gain trust with the - :STO
defense against foreign After 4h of .client ) Goal met (
materials that can be nursing intervention, Inspected skin on daily - To determine unusual ties - After 4h of nursing
considered as injuring the patient will be basis, observed for and report it to physician to intervention, the patient
agents. Once skin is :able to .changes, and unusual ties .prompt treatment :was able to
disrupted this will put a Participate in - participate in -
person at risk since it prevention measures :TX prevention measures and
may become a good and treatment .Performed bedside care - To enhance patient's self - .treatment program
medium for bacterial .program esteem and to provide comfort Maintain physical -
growth. Ectopic Maintain - .to the patient well-being and manage
pregnancy, like any .physical well-being kept the area clean, - This will assist body's - .situation
other surgical Ability to - carefully dress the wound .natural process of repair
procedures includes .manage situation side, supported incision,
invasion of the inside .and prevented infection
body, specifically the Administered -
skin and subcutaneous :LTO medication such as :LTO
.area After 16h of .antibiotics To prevent post operative - ) Goal met (
nursing intervention, Provided optimum - .wound complication After 16h of nursing
the patient will be nutrition such as increased To provided a positive - intervention, the has able
able to display .protein intake .nitrogen to aid in healing to display timely healing
timely healing of of skin lesions /wound
skin lesions / :EDX .without complication
NANDA 9th edition pp ( wounds without Encourage the patient -
) 461-465 .complication to demonstrate good skin
.hygiene Maintaining clean, dry skin -
Encouraged to wash - .provides a barrier to infection
Med-surgical Nursing, ( thoroughly and pat day
Black and Hawks 8th .carefully after cleaning
) Edition pp 952-954 Patting skin dry instead of -
rubbing reduces risk of dermal
.trauma to fragile skin

NANDA 9th edition pp 461- (

) 465

Med-surgical Nursing, Black (

and Hawks 8th Edition pp 952-
) 954