ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALLE EVALUATION

S
INDEPENDENT
CUES Impaired Skin/ After 3 days of After 3 days of
Subjective: Tissue Integrity nsg.  Establish • To gain trust nsg.
r/t trauma 2° to interventions, rapport with the client. interventions the
cesarean the patient will patient was able
section. be able to • To enhance to display timely
display timely  Perform patient’s self healing of skin
Objective: healing of skin bedside care esteem and to lesions/ wounds
lesions/ wounds provide without
Destruction of without comfort to the complication.
skin layers complication. patient.
Disruption of  Inspect skin on • To determine • Goal was met
tissue layers daily basis and unusual ties
observe for and report it to
(+) Redness on changes and physician for
the incision site unusual ties. prompt
treatment.
(+) Swelling on  Keep the area
the incision site clean, carefully • This will assist
dress wound, body’s natural
support process of
incision, repair.
prevent
infection.

 Encourage • Maintaining
client to clean, dry skin
demonstrate provides a
good skin barrier to
hygiene, e.g., infection.
wash Patting skin
thoroughly and dry instead of
pat dry rubbing
 carefully after reduces risk of
teaching. dermal trauma
to fragile skin.

DEPENDENT
• To prevent
 Medications post operative
such as wound
antibiotics. complication.

COLLABORATIVE

 Provide • To provide
optimum positive
nutrition such nitrogen
as increased balance to aid
protein in healing.
intake.