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Assessment Nursing Planning Implementation Scientific Rationale Evaluation

Diagnosis

Subjective: Impaired skin After the shift the Independent: After the shift of
integrity related patient will be able to: nursing
to surgical - Note skin - To assess intervention:
procedure. - Maintain colour, extent of
Objective: optimal texture and environment/i The goal was
nutrition and turgor njury met. The patient
Paint at the physical was able to
surgical site with being. - Palpate - To determine maintain optimal
pain score of 8 - Participate in surgical the degree nutrition and
out of 10 prevention incision for and depth of physical being.
measures and size, injury or The patient was
Disruption of treatment shape, damage to Able to
skin layers program consistenc integumentary participate in
- Verbalize y, texture, system prevention
Invasion of body feelings of temperatur measures and
structures increase self- e, and treatment
esteem and hydration program as
ability to and evidence by
manage determine cooperation. And
situation skin layer was able to
verbalize
- Inspect - To assess for feelings of
surroundin complications increased self-
g skin for and infection esteem and
erythema ability to manage
or situation by
inflammatio demonstrating a
n and note positive attitude
odours
emitted
from the
surgical
incision
- Inspect - To promote
skin on optimal
daily basis, wound
describing healing
wound
characterist
ic and
changes
observed

- Keep the - To assist


area clean body’s natural
and dry, process of
carefully repair
dressed