ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

Objective: Impaired skin The After 8 hours  Assess  Verifies status of Goal met
and tissue skin, cornea, of nursing incisions, healing, provides
 With CTT integrity r/t subcutaneous intervention, noting for early  No signs of
in Right post surgical tissues, and the pt. must approximation detection of infection and
lung procedure mucous be able to: of wound developing bleeding at
membranes act edges, complications the site
 With as a physical o Manifest hematoma requiring prompt
dressing, barrier no signs formation and evaluation and
dry, clean preventing of resolution, and influencing
and intact penetration ag infection presence of choice of
ainst threats bleeding and interventions
from the o Manifest drainage
external no signs
environment. of  Assess changes  Fever is a
These defenses bleeding in body systemic
are always at the temperature, manifestation of
ready and affected specifically inflammation
prepared to site increased in and may
defend the body indicate the
body from any temperature. presence of
harmful infection.
substances.
However,  Provide routine  Promotes
these tissues incisional care, healing.
can be being careful to Accumulation
damaged by keep dressing of serosanguine
several dry and sterile. o-us drainage in
circumstances. Assess and subcutaneous
Factor that can maintain layers increases
cause injury or patency of tension on
tissue damage drain. suture line, may
include delay wound
physical healing,
trauma and serves as a
medium for
bacterial growth

 Provide  Moisture or
meticulous excoriation
skin care enhances
growth of
bacteria that can
lead to
postoperative
infection.

 Administer anti  Wound

biotics as infections may
ordered. be managed
well and more
efficiently with
topical agents,
although
intravenous anti
biotics may be
indicated.

 Teach relatives  Early

about skin and assessment and
wound intervention
assessment and help prevent the
ways to development of
monitor for serious
signs and problems.
symptoms of
 infection,
complications,
and healing.

 Instruct  Accurate
significant information
others, and increases the
family in patient’s ability
proper care of to manage
the wound therapy
including hand independently
washing, and reduce risk
wound for infection.
cleansing,
dressing
changes, and
application of
topical
medications).
ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
Objective: Imbalanced The body is After 3 days Review laboratory Determining the Goal met:
nutrition: less like a machine of nursing values that indicate patient’s nutritional
 RBC:4.2 than body that needs to intervention, well-being or status. An abnormal  RBC: 5
requirement be supplied the pt. must: deterioration. value in a single
 WBC:5 r/t inability to with the right diagnostic study may  WBC: 12.4
ingest food kind and have many possible
 K:5.5 amount of fuel. o Display causes.  K: 3.6
This may refer normaliz
 Na: 121 to nutrition or ation of  RBC and WBC  These counts are  Na: 143
the food laborator counts frequently dropped
 CBG: 88 requirements y results in malnutrition,
mg/dl of a person or o Not revealing anemia,  CBG: 115
patient. manifest and reduced mg/dl
 With NGT Adequate hypoglyc resistance
nutrition is aemia to infection.  With OF of
 sluggish essential to 1600 Kcal in
and meet the o Take  Serum electrolyte  Potassium is 6 divided
fatigued in body’s adequate values typically elevated, feedings
appearance demands. amount and sodium is
Several of typically lowered  No signs of
diseases can calories in malnutrition. malnutrition
greatly affect or
the nutritional nutrients.  Look for physical  The patient
status of an signs of poor encountering
individual, this o Be free nutritional intake. nutritional
includes of signs deficiencies may
gastrointestinal of resemble to be
malabsorption, malnutriti sluggish and
burns, cancer; on fatigued. Other
physical manifestations
factors
(e.g., muscle w include decreased
eakness, poor attention span,
dentition, activ confused, pale and
ity intolerance, dry skin,
p[ain, subcutaneous
substance abus tissue loss, dull
e); social and brittle hair,
factors (e.g., and red, swollen
economic tongue and mucous
status, membranes.
financial
constraint);  Check CBG as  Poor nutritional
psychological ordered intake may cause
factors (e.g., hypoglycemia
boredom,
dementia, depr  Give OF feeding  Nutritional support
ession). as ordered may be
recommended for
patients who are
unable to maintain
nutritional intake
by the oral route. If
gastrointestinal
tract is functioning
well, enteral tube
feedings are
indicated.
ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
Objective: Impaired Bladder After 8 hours  Assess voiding  Identifies Goal met
urinary dysfunction of nursing pattern characteristics of
 With IC to elimination may lead to intervention, (frequency and bladder function  Still with
HCB r/t sensory impairment in the pt. must amount). (effectiveness of clear,
motor urinary be able to: Compare urine bladder emptying, yellowish,
 With clear, dysfunction elimination output with fluid renal function, and odor-free
yellowish which may o Prevent intake. fluid balance). urine
urine result to urinary Note: Urinary
urinary retention/ complications are a  (-) bladder
 (-)bladder retention/incon urinary inf major cause of distention
distention tinence ection. mortality.
 Intake: 1020
o Maintain  Palpate for  Bladder ml
balanced bladder dysfunction is
I&O with distension and variable but may  Output: 850
clear, observe for include loss of ml
odor-free overflow. bladder contraction
urine, free and inability to
of bladder relax urinary
distension sphincter, resulting
/urinary in urine retention
leakage. and reflux
incontinence.

 Observe for  Signs of urinary

cloudy or bloody tract
urine, foul odor. or kidney infection
that can
potentiate sepsis.

 Cleanse perineal  Proper perineal

area and keep hygiene decreases
 dry. Provide risk of skin
catheter care as irritation or
appropriate. breakdown and
development of
ascending
infection.

 Measure Intake  Serves as an

and output and indicator of fluid
record balance. Urinary
output <30ml may
indicate urinary
retention