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NCP Impaired Skin Integrity

- The nursing care plan is for a patient named Mr. Benitez who underwent a laparoscopic cholecystectomy and is experiencing impaired skin integrity and abdominal pain as a result of altered biliary drainage. - The nursing interventions include frequent dressing changes to keep the incision clean, applying petroleum jelly gauze and using low-Fowler's position to facilitate drainage and prevent bile backup at the incision site. - The plan also involves checking and ensuring free flow of drains, administering antibiotics as needed, and positioning the patient to promote healing and prevent further skin breakdown around the incision.

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Marc Johnuel Humangit
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89 views2 pages

NCP Impaired Skin Integrity

- The nursing care plan is for a patient named Mr. Benitez who underwent a laparoscopic cholecystectomy and is experiencing impaired skin integrity and abdominal pain as a result of altered biliary drainage. - The nursing interventions include frequent dressing changes to keep the incision clean, applying petroleum jelly gauze and using low-Fowler's position to facilitate drainage and prevent bile backup at the incision site. - The plan also involves checking and ensuring free flow of drains, administering antibiotics as needed, and positioning the patient to promote healing and prevent further skin breakdown around the incision.

Uploaded by

Marc Johnuel Humangit
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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LYCEUM-NORTHWESTERN UNIVERSITY

COLLEGE OF NURSING
Tapuac District, Dagupan City, Pangasinan
NURSING CARE PLAN

Name: __________________________________________ Date: _________________


Year & Block: ____________ Clinical Instructor: ______________________________________

Patient’s Name / Case Number: Mr. Benitez


NURSING DIAGNOSIS: Impaired Skin Integrity r/t Altered Biliary Drainage Secondary to Laparoscopic Cholecystectomy
Medical Diagnosis: Cholelithiasis
Expected Outcome: Achieve timely wound healing without complications.
Demonstrate behaviors to promote healing/prevent skin breakdown.
Target Date:
ASSESSMENT IMPLEMENTATION RATIONALE EVALUATION
- The patient verbalized unrelieved  Change dressings as often as  Keeps the skin around the o After 5 days of Nursing
pain. necessary. Clean the skin with soap incision clean and provides a Implementation the client
and water. Use sterile petroleum jelly barrier to protect the skin from achieved timely wound healing
Objective: gauze, zinc oxide, or Karaya powder excoriation. without complications and
 Abdominal Pain around the incision. demonstrates behaviors to
 Fever and Chills promote healing/prevent skin
 Nausea and Vomiting  Apply Montgomery straps.  Facilitates frequent dressing breakdown.
 Loss of Appetite changes and minimizes skin
 (+) Facial Grimace trauma.

Vital Signs taken as follows:


 Temperature: 38.6°C  Use a disposable ostomy bag over a  Ostomy appliances may be used
 Pulse: 89 bpm stab wound drain. to collect heavy drainage for
 Heart Rate: 22 cpm more accurate measurement of
 Blood Pressure: 120/80 mmHg output and protection of the skin.
 O2 Saturation: 97%
 Place the patient in a low- or semi-  Facilitates drainage of bile.
Fowler’s position.
 Check the T-tube and incisional  T-tube may remain in the
drains; make sure they are free- common bile duct for 7–10 days
flowing. to remove retained stones.
Incision site drains are used to
remove any accumulated fluid
and bile. Correct positioning
prevents the backup of the bile in
the operative area.

 Maintain T-tube in a closed collection  Prevents skin irritation and


system. facilitates measurement of
output. Reduces the risk of
contamination.

 Anchor drainage tube, allowing  Avoids dislodging tube and/or


sufficient tubing to permit free turning occlusion of the lumen.
and avoid kinks and twists.

 Clamp the T-tube per schedule.  Tests the patency of the common
bile duct before the tube is
removed.

 Administer antibiotics as indicated.  Necessary for treatment of


abscess and/or infection.

______________________________________________ __________________________________________________
Patient/ Significant Other’s Signature Student Nurse’s Signature

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