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NURSING CARE PLAN PRIORITY NO.

2 ASSESSMENT Subjective: N/A Objective: Lacerations on the perineal area Bleeding on the perineal area Redness on the perineal area DIAGNOSIS Impaired tissue integrity related to the presence of lacerations on the perineal area PLANNING After 3 weeks of nursing intervention, the client will be able to display progressive improvement in wound or lesion healing. INTERVENTION >Record size (depth, width), color, smell, location, temperature, texture, consistency of wounds/lesions if possible. >Inspect lesions/wounds daily for changes (i.e., signs of infection/complication or healing). >Promote good nutrition with adequate protein and calorie intake, and vitamin/mineral supplements as indicated. >Promote early mobility. Provide position changes active/passive and assistive exercises. RATIONALE Provides comparative baseline EVALUATION After 3 weeks of nursing intervention, the client displayed progressive improvement in wound or lesion healing. After 3 hours of nursing intervention, the client verbalized understanding of condition and demonstrated behavior and lifestyle changes to promote healing and prevent complications or recurrence.

After 3 hours of nursing intervention, the client will be able to verbalize understanding of condition and demonstrate behavior and lifestyle changes to promote healing and prevent complications or recurrence.

Promotes timely intervention/revision of plan of care

To facilitate healing

To promote circulation and prevent excessive tissue pressure.

>Practice aseptic technique for Reduces risk of cleansing/dressing/medicating cross-contamination lesions. >Discuss importance of early detection and reporting of changes in condition or any unusual physical discomforts/changes. NURSING CARE PLAN PRIORITY NO. 3 Promotes early detection of developing complications

ASSESSMENT Subjective: N/A Objective: Impaired ability to turn side to side Functional level classification of 2 as evidenced by the clients sister-in-law assisting her to move from supine to sitting position

DIAGNOSIS

PLANNING

INTERVENTION >Observe skin for reddened areas/shearing. Provide regular skin care as appropriate.

RATIONALE

EVALUATION After 1 week of nursing intervention, the client: a. Maintained position of function and skin integrity, as evidenced by absence of contractures, footdrop, decubitus, and so forth. b. Maintaned or increased strength and fuinction of affected and/or compensatory body part After 1 hour of nursing intervention, the client: a. Verbalized understanding of situation/risk factors, individual therapeutic regimen, and safety measures. b. Demonstrated techiniques/behaviors that enable safe repositioning.

Impaired bed mobility After 1 week of nursing related to perineal incisions intervention, the client will: a. Maintain position of function and skin integrity, as evidenced by absence of contractures, footdrop, decubitus, and so forth. b. Maintain or increase strength and function of affected and/or compensatory body part. After 1 hour of nursing intervention, the client will: a. Verbalize understanding of situation/risk factors, individual therapeutic regimen, and safety measures. b. Demonstrate techniques/behaviors that enable safe repositioning.

>Assist on/off bedpan Facilitates and into sitting position if elimination possible. >Administer medication prior to activity as needed for pain relief. >Observe for change in strength to do more or less self-care >Assist with activities of hygiene, toileting, feeding. >Involve client/SO in determining activity schedule. >Encourage continuation of exercises. Promotes commitment to plan, maximizing outcomes To maintain/enhance gains in strength/muscle control. To permit maximal effort/involvement in activity

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