NURSING CARE PLAN FOR IMPAIRED SKIN INTEGRITY

NURSI SCIENTI
ASSESS NG FIC PLANNIN INTERVENT EVALUATI
RATIONALE
MENT DIAGN BACKGR G IONS ON
OSIS OUND
SUBJEC Impaired An SHORT- INDEPENDE Goal met
TIVE skin alteration TERM NT: After 4
DATA: integrity in the skin GOAL:  Protect hours of
“Adda related or the After 4  Reinforce wound from performing
man dait to dermis, hours of initial mechanical nursing
tuy tiyan effected which performing dressing injury and intervention
kon han of caused by nursing and change contaminati s was able
met lang medicati surgical interventio as on to achieve
ngata on and incision. ns the indicated. wound
mapisang altered patient will Use aseptic healing as
toy kudil metaboli achieve technique  Reduces evidence
ko ” as c state as timely risk of skin by:
verbalized evidence wound  Gently trauma and  Demonst
by the by healing. remove tape disruption rate
patient disruptio (in direction of wound behaviors
n of skin LONG- of hair and
OBJECTI surfaces TERM growth) and technique
VE and GOAL: dressings s after
DATA: tissues. Patient will when  Early the
-Impaired demonstrat changing recognition operation
skin e behaviors of delayed
integrity and  Inspect healing or
-Lethargy techniques wound developing
-Low self to promote regularly, complicatio
esteem healing and noting ns may
to prevent characteristi prevent a
VITAL complicati cs and more
SIGNS: ons. integrity. serious
Temperatu Note situation
re: 36.5°C patients at
Pulse risk for  Provides
Rate: 95 delayed additional
bpm healing support for
Respiratio high-risk
ns: 18 cpm  Use incisions
BP:130/90 abdominal (obese
mmHg binder if patient).
indicated.
 Patient may
feel pain
after the
DEPENDEN effects of
T: anesthesia
 Administeri subsided
ng
medications
 as ordered
by the
attending
surgeon and  Anesthesiol
needed by ogist may
the patient evaluate
your
medical
COLLABORA condition
TIVE: and
 Refer to formulate
anesthesiol an
ogist anesthetic
plan that
takes your
physical
condition
into
account.
 NURSING CARE PLAN RISK FOR INFECTION

NURSIN
ASSESSME G INTERVENTIO EVALUATI
PLANNING RATIONALE
NT DIAGNO NS ON
SIS
SUBJECTI Risk for SHORT- INDEPENDEN Goal met
VE DATA: infection TERM T: After 2 days
“Adda met related to GOAL:  To evaluate of
lablabaga na invasive After 45  Note. Risk presence of performing
tuy dait na” procedures mins. of factors of infection nursing
as verbalized and performing occurrence of interventions
by the surgical nursing infection was able to
patient incision as interventions  Protect wound achieve free
evidence the patient  Reinforce from sign of
OBJECTIV by redness will verbalize initial dressing mechanical infection as
E DATA: of the understandin and change as injury and evidence by:
-Redness of surgical g of indicated. Use contamination  No
the surgical site. willingness to aseptic occurrenc
site follow up technique e or sign
-Pain scale 8 prescribed  To evaluate and
out 10  regimen.  Observe for presence of symptoms
localized sign infection of
VITAL LONG- and symptoms infection
SIGNS: TERM of invasive
Temperature GOAL: lines in the
: 36.5°C After 2 days surgical site
Pulse Rate: of nursing  To determine
95 bpm intervention DEPENDENT: effectiveness of
Respirations: the patient  Administer therapy and if
18 cpm will be free and instruct there is a sign
BP:130/90 from sign and precautions of adverse
mmHg symptoms of regarding effects
infection medications
regimen.
Note patient
response.

COLLABORATI  Anesthesiologi
VE: st may evaluate
 Refer to your medical
anesthesiologis condition and
t formulate an
anesthetic plan
that takes your
physical
condition into
account.