NURSING CARE PLAN

NCP 3 – Scenario 4

ASSESSMENT NURSING BACKGROU GOALS OF NURSING RATIONALE EVALUATION

DIAGNOSIS ND CARE INTERVENTION
Objective: Risk for Impaired Susceptible to NOC: Skin NIC: Skin GOAL MET IF:
emergency Skin Integrity alteration in control Surveillance
hysterectomy related to surgical epidermis and/or
after 2 hours incision during dermis, which Goal: After 2
the recovery may compromise weeks of nursing Interventions:
period. health. (NANDA, interventions, the During the health
15th Edition) client will exhibit care, the student nurse
optimal skin will:
integrity and
demonstrate
knowledge of
preventive
measures to
maintain skin
health during the
recovery period.

OBJECTIVES:
After
implementing the
nursing
intervention the
client will be able
to:
1. Initiate early-
1. The assessment 1. The
client’s within 24 Early client’s
wound hours assessment wound
decreases postoperativel within 24 hours decreases
in size y and ensures timely in size
 and has continue detection of any and has
increased throughout incision-related increased
granulatio the recovery issues, granulatio
n tissue period. supporting n tissue
Inspect the prompt
surgical intervention.
incision daily
for signs of
infection,
such as
redness,
swelling, or
discharge.

2. Administer
postoperative
2. The client pain relievers Starting use of 2. The client
reports as prescribed pressure relief reports
pain relief by the measures pain relief
at the site physician and within 48 hours at the site
of tissue demonstrate aims to prevent of tissue
impairme deep pressure ulcers impairme
breathing early in the
nt nt
exercises to recovery
relieve pain period.
and promote
comfort

3. Provide a
3. Demonstr return
ate proper demonstration A return 3. The client
technique of proper skin demonstration was able
s for care within 48 within 48 hours to
caring for hours confirms the demonstr
the postoperativel client's ate proper
 surgical y. understanding technique
incision and ability to s for
and apply proper caring for
surroundi skin care the
ng skin. techniques. surgical
incision
and
surroundi
4. Achieve ng skin.
independent
management Attaining 4. The client
4. Maintain of nutrition
optimal independence was able
and hydration in nutrition and
nutritiona to
within 72 hydration
l intake maintain
hours management
and optimal
postoperativel within 72 hours
hydration nutritiona
y and supports the
levels l intake
continue overall well-
independe and
throughout being of the
ntly. hydration
the recovery client during levels
period. the recovery independe
period. ntly.