Nurse Care Plan

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WAYNE COUNTY COMMUNITY COLLEGE DISTRICT NURSING PROGRAMNURSING CARE PLAN General Information: Postop pt undergone a cholecystectomy
Patient intials: R.M.Confidential Marital Status: SINGLEStudent’s Name: Hanadi Abdou Age: 61 Birthdate: 12/3/1950 Religion: not specified (pt nonverbal) Clinical Instructor: Mary ServeyAdmittance date: 3/12/12Interest: not specified (pt nonverbal) Date: 3/21/12 Class: Med Surg Diagnoses: Impaired skin integrity Diet: NPOAllergies: None

ASSESSMENT| GOAL| INTERVENTIONS| RATIONALE | EVALUATION| O: 61 year old post op pt has gone cholecystectomy. Pt is nonverbal and immobile. Pt has stage 2 breakdown on scrotum and stage 1, 2x2 redness around anus Nursing Diagnosis:Impaired skin integrity related to physical immobilization AEB Stage 2 skin breakdown on scrotum, and stage 5 skin impairment on anus Theoretical Knowledge:Targeting variables can focus assessment on particular factors and help guide the plan of care and prevention | 1. 1 pt will not have breakdown of skin around anus throughout shift 2. 1 Report any alteration in redness or pain at site of skin impairment q4 hrs3. 1 Regain skin integrity of skin surface within a month | 1.1 Assess site of skin impairment and determine etiology. Implement position changing to reduce pressure of site. 0800 Pressure ulcer Stage 1 break down around anus, stage 2 breakdown on scrotum.0900 cleaned bowel movement and applied topical ointment. Positioned pt on left side line position.Wound was very red, and breakdown was present around scrotum1100 cleaned bowel movement, applied topical ointment and positioned client on right side lying position. Applied a dressing cushion around anal area. 2.1 Monitor site of skin impairment at least twice a day for color changes, redness swelling or other signs of infection.0900 Cleaned bowel movement and applied topical ointment. Wound was very red, swollen and breakdown was present around scrotum1100 Cleaned...
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