NURSING CARE PLAN

Name of Patient: E. N.M Attending Physician: Dr. G.

Age: 60 years old Ward/Bed No.: Room 320 Impression/Diagnosis: Rectal Adenocarcinoma stage 1 S/P colonoscopy Polypectomy

Clustered Cues Nursing Diagnosis Rationale
Date and Time: Impaired Skin Altered epidermis and/or
September 11, 2017 Integrity related to dermis.
11:03 AM surgical incision
Incision done on the midline
Objective Cues: ( from the umbilicus to the
1. Presence of pressure symphysis pubis) to remove
and trauma in the area the disease tissue. Surgery
of incision. involves cutting or
penetration of the skin
2. Reports of pain surface and injury or trauma
on the skin and tissue is
3. incision site of 4 inflicted. Because of the
inches from the injury there is vasodilation
umbilicus to the to hurriedly send the
symphysis pubis nutrients in the body via
bloodstream ( redness and
slight edema on the skin
surrounding the incision
site.)
Outcome Criteria Nursing Interventions Rationale Evaluation
After 3 hours of nursing 1. Assess characteristics of 1. These findings give Date and Time:
intervention, the patient wound, including color, information on extent of September 11, 2017
must: size, drainage, and odor. injury. 02:00 PM
PARTIALLY MET
1. display timely 2. Assess changes in body 2. Fever is a systemic
healing of skin temperature. manifestation of After 6 hours of
lesions, wounds inflammation and may nursing intervention, the
or pressure sores. indicate presence of patient was able to:
infection.
2. maintain optimum 3. Encourage crotch care. 1. maintain optimum
3. This technique reduces
nutrition and nutrition and physical
risk of infection.
physical well- well-being.
being. 4. Tell patient to avoid 4. Rubbing and
rubbing and scratching. scratching can cause 2. verbalize feelings of
3. verbalize feelings further injury and delay increased self-esteem,
of increased self- healing. and;
esteem, and;
3. participate in
5. High-protein, high-
4. participate in 5. Encourage a diet that calories diet may be prevention measures
prevention meets nutritional needs. needed to promote and treatment program.
measures and healing.
treatment
program.
 NURSING CARE PLAN
6. Encourage use of pillow, 6. To prevent pressure to
foam wedges, and injury.
pressure-reducing devices.

Sources:
Doenges, Moorhouse, Murr;
Nurses pocket guide, 13th
edition; Page 857.;
Principles of Med-Surg Vol.
1 4th Edition by Lemone and
Burke

Student's Name:__________________________________________
Clinical Instructor:________________________________________