Nursing diagnosis: risk for impaired Skin Integrity related to Trauma, surgery, difficulty in approximation of suture line of fatty tissue, Reduced vascularity, altered circulation, Altered nutritional state—obesity
Possibly evidenced by (actual)
Disruption of skin surface, altered healing
Desired Outcomes/Evaluation Criteria—Client Will
Wound Healing: Primary Intention
Display timely wound healing without complications.
Demonstrate behaviors that reduce tension on suture line.
Tissue Integrity: Skin and Mucous Membranes
Display intact skin free of signs of pressure or breakdown.
Nursing intervention with rationale:
1. Support and instruct client in incisional support when turning, coughing, deep breathing, and ambulating.
Rationale: Reduces possibility of dehiscence and incisional hernia.
2. Observe incisions periodically, noting approximation of wound edges, hematoma formation and resolution, and presence of bleeding and drainage.
Rationale: Verifies status of healing, provides for early detection of developing complications requiring prompt evaluation and influencing choice of interventions.
3. Provide routine incisional care, being careful to keep dressing dry and sterile. Assess and maintain patency of drains.
Rationale: Promotes healing. Accumulation of serosanguineous drainage in subcutaneous layers increases tension on suture line, may delay wound healing, and serves as a medium for bacterial growth.
4. Encourage frequent positional change, inspect pressure points, and massage gently, as indicated. Apply transparent skin barrier to elbows and heels, if indicated.
Rationale: Reduces pressure on skin, promoting peripheral circulation and reducing risk of skin breakdown. Skin barrier reduces risk of shearing injury.
5. Provide meticulous skin care, pay particular attention to skin folds common in the very obese client.
Rationale: Moisture or excoriation enhances growth of bacteria that can lead to postoperative infection.
6. Provide foam, water, or air mattress, as indicated.
Rationale: Reduces skin pressure and enhances circulation.