VII.

NURSING CARE PLAN

DESTRUCTION OF SKIN LAYERS

ASSESSMENT NURSING BACKGROUND PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE
Subjective Data: The skin is a Goal: Note skin color, To document The client
Wala naman Impaired skin barrier to By the end of texture, and status and provide developed and
akong sugat kundi integrity related infectious agents; the shift, the turgor. baseline for future maintained
itong opera ko sa to post surgery however, any client will comparisons. optimal
tiyan as of the abdomen break in the skin develop and Inspect skin
verbalized by the as evidenced by can readily serve maintain conditions for
lesions for size, wound healing as
patient. sutures in the as a portal of optimal
abdominal area entry putting the conditions shape, evidenced by
Objective Data: individual at risk for wound consistency, responses to
-Disruption of for healing. texture, interventions and
skin surface potential infection temperature, and teaching and
. Objective: hydration. actions performed
After 30
minutes, the Determine and gradual
nurse will be healing of his
degree or depth
able to assess wound.
the extent of of injury or
involvement or damage to skin
injury and
provide Measure length,
comfort. width, depth of
wound.

Inspect
surrounding skin
for erythema, in
duration, and
 maceration.

Note odors
emitted from the To monitor
wound. progress of
wound healing.
Inspect skin,
describing
wound
characteristics
and changes
observed.

Measure wound
and observe for
complications.

Use appropriate
dressings, wound
coverings,
drainage
appliances for
open or draining
wounds.

Encourage Promotes
ambulation circulation and
reduces risks
associated with
immobility.
INABILITY TO TOLERATE ACTIVITIES

NURSING BACKGROUND
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS KNOWLEGDE

Subjective Activity Insufficient Long-term goal: Assessed vital To determine Goal Partially
Data: Intolerance physiological or By discharge the signs current status of Met.
Nahihirapan related to psychological patient will be patient.
akong gumalaw generalized energy to endure able to gradually The patient was
ngayon.Hindi weakness or complete increase activity Evaluated Provides basic able to
ako makakilos secondary to required or levels as clients actual information about demonstrate
masyado dahil post desired daily manifested by no and perceived the clients status ways to
sa operasyon na exploratory activities need for limitations/ conserve his
ginawa sa laparotomy as assistance in degree of deficit energy and was
kin,as evidenced by doing activities. in light of usual also encouraged
verbalized by need for status. to perform
the patient. assistance in Short term goal: activities but
doing activities. At the end of the Noted clients These symptoms still needed little
shift, the patient reports of may result to assistance from
Objective Data: will be able to: weakness and activity significant other.
Presence of difficulty of intolerance.
discomfort Demonstrate accomplishing
noted ways on how tasks.
Need for to conserve
assistance in energy. Encouraged To facilitate
doing verbalization of gathering of data.
activities Enhance feelings. Stress or
noted activity depression might
tolerance be the result of
being forced into
Verbalize inactivity.
encourage-
ment in the Planned care to To inform the
performance carefully balance patient on ways on
of activities rest periods with how to increase
intervened by activities activity tolerance.
the student
nurse. To reduce fatigue.
Provided
positive
atmosphere.
To increase
Assisted with patients activity
activities tolerance.

To provide
Encouraged the adequate
patient to adhere information and
to the activities motivate the
intervened. patient.
INABILITY TO MANAGE PERSONAL HYGIENE

NURSING BACKGROUND
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS KNOWLEDGE
Subjective Data: Self-Care Impaired ability Long-term
Patient L. G. deficit: to perform or Goal: Vital signs To serve as Goal Met.
verbalized: Bathing/ complete Before assessed and baseline data
Nahihirapan Hygiene bathing/hygiene discharge the monitored. and to keep After 8 hours of nursing
akong gumalaw related to activities for one client will be track intervention, the client
ngayon.Hindi weakness self. able to perform patients was able to:
ako makakilos secondary to self-care condition Identify individual
masyado dahil surgery done to activities within areas of weakness/
sa operasyon na patient as level of own Promoted client Enhances needs, as evidenced
ginawa sa manifested by ability. and significant commitment by:
kin,as inability to others to plan, Verbalize knowledge
verbalized by wash and dry Short-term participation in optimizing of health care
the patient. body. Goal: problem outcomes. practices, as
After 8 hours of identification evidenced by:
Objective Data: nursing and decision Verbalization of
Seen patient intervention, making. the importance of
lying on bed the client will good hygiene to
Need for be able to: Provided To assist in the health of a
assistance in Identify privacy during dealing with person.
doing individual personal care situation.
activities areas of activities.
noted weakness/
Post- needs. Identified To avoid/
exploratory Verbalize energy-saving prevent
laparotomy knowledge behaviors. fatigue and
Inability to of health injury.
wash and care
dry body or practices. Planned time To discover
body parts for listening to barriers to
 the clients/ participation
significant in regimen.
others.

Provided for Enhances

communication coordination
among those and
who are continuity of
involved in care
caring for/
assisting the
client.

Promoted client Enhances

and significant commitment
others to plan,
participation in optimizing
planning for outcomes.
care and
decision
making.

Reviewed Provides
instructions clarification,
from other reinforceme
members of the nt, and
healthcare team periodic
and provided review by
written copy. client/
caregivers.
RISK FOR INFECTION

NURSING BACKGROUND
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS KNOWLEDGE
ubjective Data: The skin is a
Inoperahan ako Risk for barrier to Long term Vital signs To serve as Goal Met.
kahapon dahil sa bato infection related infectious goal: assessed and baseline
sa daluyan ng ihi ko to inadequate agents; By discharge monitored data and to The patient was
kaya eto di pa ko secondary however, any the client will able to identify
keep track
break in the
masyado makakilos defenses not harbor patients appropriate
skin can readily
ngayon, as verbalized secondary to serve as a
infection condition. intervention to
by the patient. operation. portal of entry inside the prevent the risk for
putting the hospital after Used aseptic Invasive infection.
Objective Data: individual at the surgery. technique for procedures
risk for all invasive breach the
Received patient potential infecti Short term procedure. bodys
lying on bed on goal: protective
Exploratory After 8 hours mechanism,
Laparotomy done of nursing potentially
on December 1, interventions, allowing
2011 the patient bacteria to
will be able to enter.
identify Aseptic
interventions technique
to prevent/ reduces the
reduce risk risk for
factors. infection.

Noted signs To
and symptoms reduce/prev
of infection ent
like fever and occurrence
chills of the
 problem

Reviewed To promote
individual wellness.
nutritional
needs, and
need for rest.

Checked and To assess

monitored and monitor
patients the status of
wound dressing wound of
the patient
(determine
the color of
wound
dressing,
temperature
of the site
and
surrounding
areas, kind
of drainage,
odor, look
for any
unnecessary
drainage
like pus
formation,
etc.)

Instructed To prevent
 client in the spread
techniques to of infection
protect the and to avoid
integrity of further
skin, care for complicatio
lesions and ns
prevention of
spread of
infection.

Educated For the

patient about patient to
the signs and gain
symptoms of knowledge
infection and for early
report of
signs and
symptoms
for possible
infection.

Emphasized Premature
necessity of discontinuat
taking ion may
medications as result in
prescribed return of
infection
and
potentiate
drug-
resistant
strains .