Name of Patient: Diagnosis/Impression: NURSING CARE PLAN CUES NURSING DIAGNOSIS Impaired skin integrity related to surgery OBJECTIVES

Age:

Room Number: Attending Physician:

Hospital Number:

INTERVENTIONS

RATIONALE

EVALUATION

Subjective:

Short term
At the end of two hours nursing interventions, the patient will be able to Verbalized understanding of the condition Participate in preventive measures and treatment program

Independent Inspect surrounding skin for erythema, induration, maceration. Encourage client to inspect skin on daily basis and to describe wound characteristics and changes observed. Teach the client to keep the wound clean and to support incision (e.g. splinting, holding the area when coughing) To determine presence of complication

To monitor progress of wound healing

Objective:

Long term
At the end of two weeks nursing interventions, the patient will be able to: Display timely healing of wound without complication. Maintain optimal physical well-being. Verbalize feeling of

To prevent infection and stimulate circulation to surrounding areas to assist bodys natural process of repair.

increased selfesteem and ability to manage situation

Assist in repositioning the client on a regular schedule to a comfortable position. Encourage early ambulation or mobilization (e.g. ROM exercisesflexion of extremities)

To minimize the onset of pain while moving and prevent further complications

Promotes optimal healing, promotes circulation and reduces risks associated with immobility.

Discuss importance of early detection of skin changes and /or complications Assist the client/SO(s) in understanding and following medical regimen and developing program of preventive care and daily maintenance

To detect unusualities

Enhances commitment to plan, optimizing outcomes

Collaborative Obtain psychological assessment of clients emotional status, as indicated. Refer to dietician in the provision of optimum nutrition, including proper diet rich in vitamins (e.g. A, C, D, E) and proteins (e.g. fish, vegetables) To determine impact of condition

To enhance skin tissue healing and to maintain general good health.