Вы находитесь на странице: 1из 2


Name of Patient: E. N.M Attending Physician: Dr. G.

Age: 60 years old Ward/Bed No.: Room 320 Impression/Diagnosis: Rectal Adenocarcinoma stage 1 S/P colonoscopy Polypectomy

Clustered Cues Nursing Diagnosis Rationale Outcome Criteria Nursing Interventions Rationale Evaluation
Date and Time: Impaired Skin Altered epidermis and/or After 3 hours of nursing 1. Assess characteristics of 1. These findings give Date and Time:
September 11, 2017 Integrity related to dermis. intervention, the patient wound, including color, information on extent of September 11, 2017
11:03 AM surgical incision must: size, drainage, and odor. injury. 02:00 PM
Incision done on the midline PARTIALLY MET
Objective Cues: ( from the umbilicus to the 1. display timely 2. Assess changes in body 2. Fever is a systemic
1. Presence of pressure symphysis pubis) to remove healing of skin temperature. manifestation of After 6 hours of
and trauma in the area the disease tissue. Surgery lesions, wounds inflammation and may nursing intervention, the
of incision. involves cutting or or pressure sores. indicate presence of patient was able to:
penetration of the skin infection.
2. Reports of pain surface and injury or trauma 2. maintain optimum 3. Encourage crotch care. 1. maintain optimum
3. This technique reduces
on the skin and tissue is nutrition and nutrition and physical
risk of infection.
3. incision site of 4 inflicted. Because of the physical well- well-being.
inches from the injury there is vasodilation being. 4. Tell patient to avoid 4. Rubbing and
umbilicus to the to hurriedly send the rubbing and scratching. scratching can cause 2. verbalize feelings of
symphysis pubis nutrients in the body via 3. verbalize feelings further injury and delay increased self-esteem,
bloodstream ( redness and of increased self- healing. and;
slight edema on the skin esteem, and;
surrounding the incision 3. participate in
5. High-protein, high-
site.) 4. participate in 5. Encourage a diet that calories diet may be prevention measures
prevention meets nutritional needs. needed to promote and treatment program.
measures and healing.
6. Encourage use of pillow, 6. To prevent pressure to
foam wedges, and injury.
pressure-reducing devices.

Doenges, Moorhouse, Murr;
Nurses pocket guide, 13th
edition; Page 857.;
Principles of Med-Surg Vol.
1 4th Edition by Lemone and

Student's Name:__________________________________________
Clinical Instructor:________________________________________