CULS NUkSING

DIAGNCSS
SCILN1IIC kA1ICNALL C8ILC1IVLS NUkSING IN1LkVLN1ICN kA1ICNALL LVALUA1ICN
SU8ILC1IVL














C8ILC1IVL













k|sk for
Impa|red Sk|n
Integr|ty re|ated
post op
lndependenL
1 lnspecL all lnclslons LvaluaLe
heallng progress 8evlew
expecLaLlons for heallng wlLh
paLlenL
2 SuggesL wearlng sofL coLLon
shlrLs and looseflLLlng
cloLhlng leavlng lnclslons
open Lo alr as much as
posslble coverlng or paddlng
porLlon of lnclslons as
necessary
3 Pave paLlenL shower ln warm
waLer washlng lnclslons
genLly 1ell paLlenL Lo avold
Lub baLhs unLll approved by
physlclan
4 Lncourage elevaLlon of leg s
when slLLlng up ln chalr
3 8evlew normal slgns of
heallng eg lLchlng allow
wound llne brulslng llghL
redness scabblng lnsLrucL Lo
waLch for /reporL Lo physlclan
places ln lnclslon LhaL do noL
heal reopenlng of healed
lnclslon any dralnage( bloody
or purulenL)locallzed area
LhaL ls swollen wlLh redness
feels lncreaslngly palnful and
ls hoL Lo Louch LemperaLure
greaLer Lhan 1013 l (386 C)
Peallng beglns lmmedlaLely buL
compleLe heallng Lakes Llme As
heallng progresses Lhe lnclslon llnes
may appear dry wlLh crusLy scabs
underlylng Llssue may lock brulsed
and feel Lense warm and lumpy
(resolvlng hemaLoma)
8educes suLure llne lrrlLaLlon and
pressure from cloLhlng Leavlng
lnclslons open Lo alr promoLes
heallng process and may reduce rlsk
of lnfecLlon





keeps lnclslon clean promoLes
clrculaLlon or heallng






romoLes clrculaLlon reduces
edema Lo lmprove Llssue heallng

Pelps paLlenL undersLand expecLed
progresslon of heallng and recognlze
slgns o compllcaLlons/ nonheallng
requlrlng furLher

for longer Lhan 24 hours
6 romoLe adequaLe nuLrlLlonal
and fluld lnLake



CCLLA8C8A1lvL

CbLaln speclmen of wound dralnage
as lndlcaLed
evaluaLlon/lnLervenLlon noLe
lnclslonal problems rank second
behlnd chesL paln as cause of
readmlsslon posL CA8C

















Pelps promoLes good clrculaLlng
volume for Llssue perfuslon and
meeLs cellular energy requlremenLs
Lo faclllLaLe Llssue regeneraLlon/
heallng process


lf lnfecLlon occurs local a sysLemlc
LreaLmenLs may be requlred eg
peroxlde/ sallne/ beLadlne soaks/
anLlbloLlc Lherapy


CULS NUkSING
DIAGNCSIS
SCILN1IIIC
kA1ICNALL
C8ILC1IVLS NUkSING IN1LkVLN1ICN kA1ICNALL LVALUA1ICN
SU8ILC1IVL











C8ILC1IVL



















Acute pa|n post
op
INDLLNDLN1
1 Note type] |ocat|on of
|nc|s|on
2 Lncourage pat|ent to report
type |ocat|on and |ntens|ty of
pa|n rat|ng on a sca|e of 0
10 Note assoc|ated
symptoms



3 Cbserve for anx|ety
|rr|tab|||ty cry|ng
rest|essness s|eep
d|sturbances
4 Mon|tor v|ta| s|gns












S Ident|fy and promote pos|t|on
of comfort us|ng ad[uncts as
necessary





a|n |s perce|ved man|fested and
to|erated |nd|v|dua||y It |s
|mportant for pat|ent to
d|fferent|ate |nc|s|ona| pa|n pa|n
from other types of chest pa|n

1hese nonverba| cues may
|nd|cate the presence]degree of
pa|n be|ng exper|enced

neart rate usua||y |ncreases w|th
pa|n a|though a bradycard|ac
response can occur |n a severe|y
deseased heart 8 may be
e|evated s||ght|y w|th |nc|s|ona|
d|scomfort

|||ows] b|anket ro||s are usefu| |n
support|ng extemet|es ma|nta|n|ng
body a||gnment nd sp||nt|ng
|nc|s|ons to reduce musc|e tens|on]
prom|te comfort
May promote re|axat|on] red|rect
attent|on and reduce ana|ges|c
dosage needs] frequeny















6 rov|de comfort measures
(eg back rubs pos|t|on
changes) ass|st w|th se|f
act|v|t|es and encourage
d|vers|ona| act|v|t|es as
|nd|cated
7 Schedu|e care act|v|t|es to
ba|ance w|th adequate
per|ods Ass|st w|th se|f care
act|v|t|es as needed
8 Mon|tor granted act|v|ty
program Note pat|ent
response v|ta| s|gns before]
dur|ng]after act|v|ty
deve|opment of dysrythm|as




prevents fat|gue] overexhaust|on
and excess|ve card|ovascu|ar
stress



kegu|ar exerc|se st|mu|ates
c|rcu|at|on] card|ovascu|ar tone
and promotes fee||ng of we|| be|ng
rogress|on of act|v|ty depends on
card|ac to|erance