NURSING CARE PLAN

Nursing Diagnosis/ Focus: Impaired Tissue Integrity related to disruption of tissue associated with the surgical procedure
Scientific Analysis: An alteration or damage in the subcutaneous tissues. The skin is subject to injury from a variety of external and internal factors.
In patients case it as due to tissue trauma on the surgical incision site from her recent surgery caused by myoma. The skin is a barrier or the
primary defense of the body against infections brought about by the invasion of microbes in the body. The patient has undergone surgery thus an
incision as created causing tissue damage that might promote entry of bacteria into the body.
ASSESSMENT PLANNING INTERVENTION RATIONALE EVALUATION
08/30/17 Short Term Goal Independent 8/30/17
2:30 PM 3:30 PM
After one hour of Nursing 1. Assessed site of impaired 1. For baseline date. And also,
Subjective Cues Intervention, patient must tissue integrity and its redness, swelling, burning and Short Term
Naa mani gisi diri Maam have: condition. itching are indication of Goal:
kay ge operahan man ko., 1. Verbalized inflammation and the bodys Goal Met.
as verbalized. understanding of plan to immune system response to
heal tissue and prevent 2. Assessed the characteristic localized tissue trauma.. Patient
Objective Cues injury. of wound, including size, 2. Findings will give information verbalized
- Pain rated 6/10 in 2. Demonstrated color, drainage and odor. on extent of injury. Pale tissue understanding
the pain rating measures to protect and color is a sign of decreased of condition and
scale. heal the tissue, including 3. Assessed changes in body oxygenation. Odor may be a result the signs and
- Incision wound wound care using aseptic temperature. of infection. symptoms of
approximately 5-7 technique. 3. Fever is a systemic infection. She
inches noted at 4. Performed wound care manifestation of inflammation also
hypogastric region After 14 days of Nursing using aseptic technique. and may indicate presence of demonstrated
of the abdomen Intervention (09/13/17): 5. Instructed patient to avoid infection. proper wound
covered with 1. Patients wound must rubbing and scratching of the 4. To assess the wound and care and
dressing, with have decreased in size and wound site. reduce risk for infection. measures to
minimal discharges increased in granulation 6. Taught patient on proper 5. Rubbing and scratching can prevent injury.
noted. tissue. wound care and informed the cause further injury and delay
- Guarding behavior 2. Patient must have signs of infection. healing. Long Term Goal:
noted. followed prescribed Goal not met.
therapeutic regimen. 7. Educated patient about 6. To promote independence in Evaluation date
proper nutrition (increase wound care at home and to avoid on 09/13/17.
protein intake if indicated), complications.
hydration, and methods to
maintain tissue integrity. 7. For fast wound healing and to
prevent further injury.
8. Encouraged patient to
comply with therapeutic
regimen.
9. Monitored for any 8. To prevent further
complications. complications.

9. For immediate and proper

referral.