ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONAL EVALUATION

REASON E
S:”Medyo Impaired Skin Surgical After 6 hrs of Independent >Redness Goal Met AEB:
nangangati at Integrity r/t Incision nursing >Inspect/assess or swelling (-) Scratching
mahapdi siya.”, disrupted skin ↓ intervention incision site for indicates on the incision
as verbalized layers Destruction the patient will redness, wound site after 6
by the patient. secondary to of skin avoid swelling or signs infection hours of
surgical layers scratching at of evisceration nursing
O: incision AEB ↓ the incision >Keep the >To assist intervention.
>disrupted skin verbalization of Broken skin site incision site body’s
layers itchiness on the and clean and dry, natural
>wound area is incision site, traumatized carefully change process of
warm to touch disrupted skin tissue the dressing infection
>(+)slight layers, wound ↓ >Regularly
swelling at the area is warm to Impaired clean the wound >To
incision site touch, (+) Skin aseptically promote
swelling at the integrity > Minimize skin healing and
V/S: incision site irritation prevent
T: 36.6 °C infection
P: 67 bpm >
R: 16 cpm Preventing
BP: 100/80 >Instruct skin
mmHg patient to irritation
increase intake eliminates a
of foods rich in potential
protein, source of
minerals and microorgani
vitamins sm entry
>Assess for >They aid
presence or in skin
absence of local healing
wound infection

>Instruct >Provides
patient to have for early
adequate rest detection of
and sleep developing
infectious
process
>Teach and > Adequate
assist the client rest and
in the following: sleep helps
a.supporting the in faster
surgical site healing and
when moving recovery
b.Splinting the
area when > A wound
coughing, typically
sneezing, or requires 3
vomiting weeks for
Dependent strong scar
>Administer formation.
antibiotic as Stress on
ordered the suture
line before
Collaborative this occurs
>Instruct can cause
patient’s disruption
significant
others the >To
proper way of prevent
caring wound infection
and
promote
healing