Nursing Problem Analysis Goal / Objectives Nursing Rationale Evaluation

Cues Interventions
Impaired skin Situation analysis: Goal: The client
integrity related to Impaired skin By the end of the developed and
post surgery of the integrity was due to shift, the client will maintained optimal
abdomen as the client’s tissue develop and conditions for
evidenced by trauma on the maintain optimal wound healing as
sutures in the surgical incision site conditions for evidenced by
abdominal area. from his recent wound healing. responses to
surgery caused by interventions and
O>-disruption of small bowel Objectives: teaching and
skin surface obstruction. 1. After 30 minutes, 1. Note skin color, -To document status actions performed
-destruction f the nurse will be texture, and turgor. and provide and gradual
skin layers Health Implication: able to assess the 2. Palpate skin baseline for future healing of his
The skin is a barrier extent of lesions for size, comparisons. wound.
to infectious agents; involvement or shape, consistency, NANDA 11th Edi. p.
however, any break injury. texture, 620-621
in the skin can temperature, and
readily serve as a hydration.
portal of entry 3. Determine
putting the degree or depth of
individual at risk for injury or damage to
potential infections. skin.
(Fundamentals of 4. Measure length,
Nursing by Kozier, width, depth of
et.al., 7th edition, wound.
page 633) 5. Inspect
surrounding skin for
erythema,
induration, and
maceration.
 6. Note odors
2. After the shift, emitted from the
the nurse will be wound.
able to assist the 1. Inspect skin,
client with describing wound
correcting and characteristics and -To monitor
minimizing condition changes observed. progress of wound
and promote 2. Remeasure healing.
optimal healing of wound and observe NANDA 11th Edi. p.
wound. for complications. 621
-To protect the
wound and
3. Use appropriate surrounding tissues.
dressings, wound NANDA 11th Edi. p.
coverings, drainage 622
appliances for open -Promotes
or draining wounds. circulation and
4. Encourage early reduces risks
ambulation. associated with
immobility.
NANDA 11th Edi. p.
622