NCP Impaired Skin Integrity PDF

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Summary

Nursing Care Plan: Impaired Skin Integrity...

Description

ASSESSMENT SUBJECTIVE The client verbalized, ”Tinahi nga ito eh kasi nagkaroon ng hiwa masyado raw malaki si baby saka first time ko pang manganak.” OBJECTIVE Vital signs taken as follows: T- 37.2 C PR- 72 bpm RR- 16 cpm BP- 110/80 mmHg PHYSICAL EXAMINATION FINDINGS 

1st degree laceration involving the vaginal mucosa, fourchette and perineal

NURSING DIAGNOSI S Impaired skin integrity related to 1st degree laceration that involves the vaginal mucosa, the fourchette and the perineal skin as manifested by rigid perineum and excessive size of the newborn upon delivery

PLANNING SHORT TERM GOALS After 4 hours of nursing interventions, the client will be able to: 1. Verbalize feelings of increased selfesteem and ability to manage situation 2. Verbalize increased comfort

INTERVENTION INDEPENDENT 1. Determine the client’s level of comfort 2. Determine the degree and depth of the laceration 3. Cleanse the perineal area with luke warm water and Povidone Iodine then pat with a dry towel 4. Perform routine skin inspection describing the observed changes in perineum 5. Assist the client in changing the perineal pad

LONG TERM GOALS After 1 month of nursing interventions, the client will be able to: 1. Display timely healing of

RATIONALE

6. Monitor episiotomy site using the REEDDA (Redness, Edema,Ecchymosis, Discharge,Drainage, Approximation) 7. Instruct the client on the

1.To clarify intervention needs and priorities 2. To note certain changes that will occur 3. To avoid infections

4.To identify possible signs of infections

5. To provide knowledge on how to apply and remove pads that can help to maintain the skin integrity 6. To detect signs or symptoms of possible skin infection

7. To provide non pharmacologic pain

EVALUATION After 1 month of nursing interventions, the goal was MET: Client showed signs of progressive healing as demonstrated by clean, dry and intact episiotomy site. Also, the client was able to verbalize feelings of increased selfesteem and showed ability to manage the situation and remained free of infection.

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skin Small amount of lochial discharge that saturates the perineal pad for about 4 in Presence of Pediculosi s Pubis in the pubic hair Redness of the Labia Majora Odorous scent from the perineal area

laceration without complication 2. Remain free of infection without any signs and symptoms of infection and exhibit evidence of progressive healing as demonstrated by a clean, dry and intact episiotomy site

use of warm sitz bath to promote healing

education

DEPENDENT 1. Give Ibuprofen to relieve pain as ordered by the doctor COLLABORATIVE 1. Obtain psychological assessment of the client’s emotional status, noting for potential sexual problems arising from the presence of condition

1.Relieves the pain caused by the episiotomy...