RLE 002

Cebu Normal University

College of Nursing
Cebu City
Mission-Vision: Care Using Knowledge and Compassion
6
Clients Initials:_D.C.J_________________ tressor Classifi!ation: "#lease !$e!%&
'ge:_() yo *en+er: Male Civil tatus:_Marrie+ _,eligion:_,oman Cat$oli! ___-___ #$ysiologi!al "bo+y stru!ture an+ fun!tions&
'llergies: _No %no.n foo+ an+ Drug 'llergies_____ ______ #sy!$ologi!al "mental /ro!esses an+ emotion&
Diet:___Not$ing /er 0rem_______________________________ ______ o!io-!ultural "relations$i/s1 so!ial e2/e!tations&
Date of '+mission:______January 31 456(______________ ______ /iritual "influen!e of s/iritual beliefs&
Diagnosis-Im/ression: #M780 se! to !oloni! mass s/leni! fle2ure /rob ______ Develo/mental "+evelo/mental /ro!esses over t$e lifes/an&
Malignant stage III8 t9n6m5
NURSING DIAGNOSIS NURSING GOALS NURSING OUCO!E
'ssessment Diagnosis Mutual #lanning
"*oal attainable .it$in t$e
s$ift&
Interventions
".it$ ,ationale : our!e&
'!tual ;valuation
S"#$e%&i'e(
<Uga ra man ang a%ong
tina$i-an +ay1= as verbali>e+
by t$e /atient.
O#$e%&i'e(
Received lying
on bed;
awake,
conscious and
coherent, with
ongoing IVF of
#2 PLR L
!"#gtts$%in;
with F&'
Impaired s)in in&egri&*
rela&ed &o presen%e o+
s"rgi%al in%isions
'fter ? $ours of +oing
nursing intervention1 t$e
/atient .ill be able to
/arti!i/ate in /revention
measures an+ treatment
/rogram1 +is/lay absen!e
of .oun+ !om/li!ations1
an+ maintain /$ysi!al .ell-
being.
#,IM',@ INA;,V;NAI0N
,romo&i'e(
I: 'ssess e2tent of in!ision.
,: Ao $ave baseline or basis in i+entifying
.oun+ $ealing.
: Doenges1 et.al.1 /.6451 455?
I: Note s%in !olor1 te2ture1 an+ turgor.
,: Ao $ave baseline or basis in i+entifying
.oun+ $ealing.
: Doenges1 et.al.1 /.6451 455?
I: Measure lengt$1 .i+t$1 an+ ins/e!t
!$ara!teristi! of in!ision. Note o+ors
emitte+ from t$e in!ision.
,: Ao $ave baseline or basis in i+entifying
.oun+ $ealing.
(heory)based *Betty Neuman+
NURSING CARE PLAN
,ssess%ent - .oints /oals 2 .oints Interventions " .oints &ibliogra.hy
0iagnosis - .oints (heoretical &asis 2 .oints 1valuation .oint 15 points
attached to
2&; with vital
signs of (3 -4
degrees
'elsius, P3 54
b.%, R3
2c.%, &P3
"#$6#
%%7g; one
day .ost o.;
.resence of
surgical
incision noted,
-eore&i%al #asis(
Im/aire+ s%in integrity is
+efine+ as t$e altere+
e/i+ermis an+-or +ermis.
urgery is nee+e+ to
+iagnose or !ure a s/e!ifi!
+isease /ro!ess1 !orre!t a
stru!tural +eformity1 restore
a fun!tional /ro!ess or
re+u!e t$e level of
+ysfun!tional /ain. It
involves !utting an+
/enetration or s%in surfa!e
an+ s%in layers .$i!$
infli!ts inBury an+ trauma
on t$e s%in an+ tissues.
A$is !reates a brea% a in
t$e !ontinuity of t$e s%in
an+ !reates a $ig$er ris%
for infe!tion. In a++ition1
/otential life-t$reatening
!on+itions !an arise1
reCuiring intervention in
/osto/erative /erio+. A$is
NC# is !on!entrate+ in t$e
/revention of /otential
!om/li!ations t$at .ill arise
"Doenges1 et.al.1 4554&.
: Doenges1 et.al.1 /.6461 455?
,re'en&i'e
I: ,evie. im/ortan!e of s%in an+
measures
,: Ao maintain /ro/er s%in fun!tioning.
: Doenges1 et.al.1 /.6451 455?
I: #erio+i!ally remeasure in!ision an+
observe for !om/li!ations.
,: Ao monitor /rogress of .oun+-in!ision
$ealing.
: Doenges1 et.al.1 /.6461 455?
I: Dee/ t$e area !lean an+ +ry1 !arefully
+ress .oun+s1 su//ort in!ision1 /revent
infe!tion1 an+ stimulate !ir!ulation to
surroun+ing areas.
,: Ao assist bo+ys natural /ro!ess of
re/air.
: Doenges1 et.al.1 /.6461 455?
I: ;n!ourage ambulation-mobili>ation.
,: #romotes !ir!ulation an+ re+u!esris%s
asso!iate+ .it$ immobility.
: Doenges1 et.al.1 /.6441 455?
I: 'ssist !lient in un+erstan+ing an+
follo.ing me+i!al regimen an+
+evelo/ing /rogram of /reventive !are
an+ +aily maintenan!e.
,: ;n$an!e !ommitment to /lan1
o/timi>ing out!omes.
: Doenges1 et.al.1 /.6451 455?
;C0ND',@ INA;,V;NAI0N
C"ra&i'e
I: Use a//ro/riate barrier +ressings1
.oun+ !overings1 +rainage a//lian!es1
s%in-/rote!tive agents for in!isions.
,: Ao /rote!t t$e .oun+ or in!ision an+ or
surroun+ing tissues.
: Doenges1 et.al.1 /.6451 455?
I: ,emove .et +ressings /rom/tly.
,: Moisture /otentiates s%in brea%+o.n
: Doenges1 et.al.1 /.6451 455?
I: #rovi+e o/timum nutrition1 in!lu+ing
vitamins an+ in!rease /rotein inta%e.
,: Ao /rovi+e a /ositive nitrogen balan!e
to ai+ in s%in or tissue $ealing an+
maintain general goo+ $ealt$.
: Doenges1 et.al.1 /.6451 455?
A;,AI',@ INA;,V;NAI0N
Re-a#ili&a&i'e
I: 'ssist !lient to learn stress re+u!tion
an+ alternate t$era/y te!$niCues.
,: Ao !ontrol feelings of $el/lessness an+
+eal .it$ situation.
: Doenges1 et.al.1 /.6451 455?
.i#liograp-*(
Doenges/ !aril*nn E0/ !oor-o"se/ !ar* 1ran%es/ Geissler/ Ali%e C0 N"rse2s ,o%)e& G"ide Diagnoses/ ,riori&i3ed
In&er'en&ions/ and Ra&ionales0 Edi&ion 440 10A Da'is Compan*0,-iladelp-ia02005