Nursing Process Work Sheet

Nursing Diagnosis: Impaired skin integrity r/t surgical procedure aeb abdominal incision. Kayli Moody Nursing 215
Long Term Goal: Patient will regain skin integrity.
Outcome Criteria: Interventions: Scientific Rationale: Evaluation:
1 Patient's incision will remain 1A Assess abdominal incision q Wound edges should remain 1 Met, ongoing.
intact with well- approximated shift. 1B approximated without tension,
edges throughout hospital stay. Assess steristrips for placement q puckering or open gaps. An incision
shift. 1C is most vulnerable to injury during
Change abdominal dressing if moist the first 48 hours before wound
per MD order. strength begins to develop. Wound
dehiscence occurs with excessive
stress on a new incision. Obesity or
improper techniques for mobility
may add to stress on sutures and
contribute to dehiscence. Steristrips
maintain wound approximation and
2 Patient will prevent strain on 2A Demonstrate proper splinting 2 Splinting the incision eases comfort 2. Met.
abdominal incision until follow up prior to discharge. of coughing and taking deep breaths.
appointment with provider. 2B Encourage splinting with Effective coughing clears bronchial
position changes. tree secretions. Splinting incision
2C Encourage splinting whenever when coughing or straining (position
coughing. changes) reduces the risk for wound
separation. Wound separation could
cause additional increase in pain and
risk for infection.
Nursing Care Plans, 243, 248
 Nursing Process Work Sheet

3 Patient will show no s/s of
infection prior to discharge.
3A Assess incision site for redness q
shift. 3B
Assess incision site for drainage q
shift. 3C
Demonstrate proper handwashing
with each dressing change.
3D Monitor WBC as ordered by MD.
3E Monitor VS q 4hrs.
Instruct patient to seek medical 3 Outcome met, plan is ongoing.
attention for unrelieved pain, fever,
foul smelling drainage, redness or
unusual pain in any incision or
separation of wound edges. Surgical
incision sites represent a break in the
body's normal first line of defense.
Classic signs of infection may include
localized redness, heat, swelling and
pain. Elevated WBC counts may
indicate infection.
Nursing Care Plans, 107, 245,250

4 Patient will verbalize 3 signs of
infection prior to discharge.
4A Teach s/s of infection prior to 4 Early treatment promotes .
discharge. 4B recovery. Change in mental status,
Observe patient's handwashing fever, shaking, chills and hypotension
technique before discharge. are indicators of sepsis. A successful
infection prevention program can
provide the foundation for expanding
performance improvement and
health maintenance. Patient must
also know how to identify problems
and needs to know what to do if they
occur. Handwashing remains the
most effective method of infection
control. Nursing Diagnosis Handbook
483 Nursing Care Plans 246, 250
 Nursing Process Work Sheet
5 Patient will ambulate at least 2x 5A Encourage ambulation at least
per shift as tolerated. 2x per shift.
5B Assess pain level 1 hr before
ambulation.
5C Administer PRN pain medication Ambulation may increase peristalsis
per MD order/ pain scale.
Outcome Criteria Interventions
6 Patient will consume adequate 6A Educate patient re: increased
nutrition to promote healing prior protein needs before discharge.
to discharge. 6B Encourage fluids q4 hours.
6C Encourage adequate nutritional
intake each meal.
5 An experimental sudy of 420 5 Met, ongoing plan.
individuals found early ambulation
improved comfort. Decreased
mobility can lead to constipation.
which is necessary to prevent
constipation and increase comfort.
Nursing Diagnosis Handbook, 242
Assessment of the pain experience is
the first step in planning pain
management strategies. The patient
is the most reliable source of
information about his or her pain. A
visual; or descriptive scale can be
used to identify the extent of pain.
Nursing Care Plans, 145
Scientific Rationale Evaluation
6 A high protein diet may be needed 6 Met, ongoing.
to promote healing. Patients
experiencing nutritional deficiencies
may appear listless and fatigued.
Adequate intake of protein, vitamins
and minerals is essential to promote
immune system function and wound
healing. Adequate nutritional intake
including calories, fatty acids and
protein is required for optimal would
healing. Encouraging fluids after
surgery helps with fluid replacement.
Nursing Care Plans 136, 137 Nursing
Diagnosis Handbook, 246