Question

Please use this scenario for wound care documentation. Scenario: A 28-year-old female who had abdominal surgery 6 days ago. Admitting Diagnosis: Wound Dehiscence VS: T-100.0, P-102, R-22, 02 Sat. 98% Pain level: 4/10 at the wound site MD orders: Saline Moist dressing every shift Acetaminophen 500 mg PO q 4 hrs. PRN for pain Wound culture Please follow the Rubric to obtain higher points.

Answer 1

NANDA Nursing diagnosis :-

1. Risk for wound infection related to wound dehiscence characterised by fever , tachycardia and wound rupture

2. Impaired skin integrity related to wound infection as evidenced by the rupture of wound infection

3. Disturbed body image related to wound rupture as evidenced by the facial expressions.

#. Nursing Interventions

- Multidisciplinary care planning needed

- Encourage patient independence and patient accomplishments

- Educate patients/families about how to minimize factors that impair wound healing