- Assess post-op wound for drainage, bleeding, signs of infection, abnormal swelling or dehiscence.
- Collaborate with interdisciplinary team.
- Educate patient/family regarding dressing changes and wound care, importance of adequate nutrition, signs and symptoms of infection, use of medications, frequent positional changes, and increasing activity, as tolerated.
- Provide wound care and dressing changes daily or PRN.
Damage to the integumentary, corneal, or mucous membranous
Practice (8th ed.). Philadelphia: Lippincott
3. Wilkinson, J. M. (2005) Nursing diagnosis handbook (8th ed). Upper
Saddle River, NJ: Prentice Hall.
tissues of the body, including full-thickness (including Stage IV
Pressure Sores) or surgical wounds.3
1. NANDA International (2005). Nursing Diagnoses: Definitions &
Classification 2005-2006. Philadelphia: Author.
2. Carpenito, L. J. (2000). Nursing Diagnosis: Application to Clinical