ASSESSMENT NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
O: Impaired skin After 8 hours of INDEPENDENT: Goal met. As evidenced
 Presence of and tissue nursing  Established - To gain trust by the patient:
surgical integrity interventions, the rapport. with the client
incision related to patient will be able  Has able to
 A site for mechanical to:  Inspected skin - To determine display timely
organism trauma of  Participate in on daily basis unusualities healing of skin
invasion surgical prevention and observe and report it to lesions\ wound
 Destruction removal of measures for changes physician for without
of skin layers akin and and treatment and prompt complications.
 Disruption of subcutaneous program unusualities. treatment.  Maintained
tissue layers. tissue  Maintain physical well-
 Disruption of secondary to physical well-  Kept the area - This will assist being.
tissue layers. caesarean being. clean, carefully body’s natural  Demonstrated
 Swelling on section.  Ability to dress wound, repair. importance of
the incision manage support good skin
site. situation incision, hygiene for
prevent body’s natural
infection. healing
specifically to the
 Encouraged - Maintaining incision.
client to clean, dry skin
demonstrate provides a
good skin barrier to
hygiene by infection.
washing Patting skin
thoroughly and dry instead
pat dry rubbing
carefully after reduces risk of
teaching. dermal trauma
to fragile skin.
DEPENDENT:
 Medication - To prevent
such as post-operative
antibiotics. wound
complication.
COLLABORATIVE:
 Provide - To provide a
optimum positive
nutrition such nitrogen
as increased balance to aid
protein intake. in healing.