NURS 156 & NURS 157 NURSING CARE PLAN Nursing Diagnosis & Scientific Rationale (with reference)

Impaired Skin Integrity related to surgical incision and percutaneous drain placement as evidenced by disruption of epidermis and dermal tissue. Nurses Pocket Guide, Diagnoses, Prioritiized Interventions, and Rationales. M. Doenges, M. Moorhouse, A. Murr. 12th Edition Expected Outcomes & Nursing Interventions Evaluation of Outcomes The patient will maintain or develop clean and dry skin (met and on going) 1.Support and instruct patient in incision support when turning, coughing, deep The patient will verbalize breathing and understanding of ambulating condition and causative 2.Observe incision factors of infection (met noting approximation of and on going) wound edges, hematoma formation, The patient will display resolution and presence progressive improvement of bleeding and in wound or lesion drainage amount, color, healing ( not met and on odor and appearance going) 3.Provide routine incisional care being careful to keep dressing dry and sterile- assess and maintain patency of drain Rationale for Interventions (with reference) 1.To reduce the possibility of dehiscence and incisional hernia. 2.To avoid or intervene and treat infection. 3. To assess and avoid infection. Nurses Pocket Guide, Diagnoses, Prioritiized Interventions, and Rationales. M. Doenges, M. Moorhouse, A. Murr. 12th Edition Evaluation of Clients Response to Interventions 1.Patient understands and is compliant with supporting her incision while ambulating, turning and coughing. 2.The staff is documenting and observing the wound changes and drainage regularly. 3.Staff is caring for incision and drainage during each shift and documenting any changes and changing bandage regularly.