Nursing diagnosis: impaired Skin/Tissue Integrity related to surgical removal of skin and tissue; altered circulation, presence of edema, drainage; changes in skin elasticity, sensation; tissue
Possibly evidenced by
Disruption of skin surface, destruction of skin layers and subcutaneous tissues
Desired Outcomes/Evaluation Criteria—Client Will
Wound Healing: Primary Intention
Achieve timely wound healing free of purulent drainage or erythema.
Knowledge: Treatment Procedures
Verbalize understanding of treatment plan to promote wound healing.
Demonstrate wound care techniques that facilitate increased tissue granulation at incision site.
Demonstrate behaviors that prevent complications.
Nursing intervention with rationale:
1. Assess dressings and wound for amount and characteristics of drainage.
Rationale: Use of dressings depends on the extent of surgery and the type of wound closure. Pressure dressings are usually applied initially and are reinforced, not changed. Drainage occurs because of the trauma of the procedure and manipulation of the numerous blood vessels and lymphatics in the area.
2. Provide drain care, instructing client/family in the process, as indicated.
Rationale: The Jackson-Pratt drain is most commonly used for mastectomies to maintain negative pressure in the wound and is easily managed. Simple mastectomies use one drain, whereas more complex procedures, such as those involving removal of lymph nodes, may require several drains. Drains are usually removed around the third day or when drainage ceases, possibly after client is discharged. Teaching facilitates self-care, reducing a major concern of client.
3. Monitor temperature.
Rationale: Early recognition of developing infection enables rapid institution of treatment.
4. Place in semi-Fowler’s position on back or unaffected side; avoid letting the affected arm dangle.
Rationale: Assists with drainage of fluid through use of gravity.
5. Prevent or minimize edema of involved arm.
Rationale: Reduces the discomfort and associated complications.
6. Elevate hand and arm with shoulder positioned at appropriate angles at no more than 65 degrees of flexion, 45–65 degrees of abduction, 45–60 degrees of internal rotation, and forearm resting on wedge or pillow, as indicated.
Rationale: Elevation of affected arm facilitates drainage and resolution of edema. Lymphedema is present in approximately 24% to 49% postmastectomy depending on surgical procedure performed (Warren et al, 2007). This may develop immediately after surgery or years later.
7. Avoid measuring blood pressure (BP), injecting medications, or inserting intravenous (IV) lines in affected arm.
Rationale: Increases potential of constriction, infection, and lymphedema on affected side.
8. Inspect donor and graft site, if done, for color and blister formation; note drainage from donor site.
Rationale: Assesses circulation of affected area. Blister formation identifies bacterial growth and infection.
9. Encourage wearing of loose-fitting, nonconstrictive clothing. Inform the client not to wear wristwatch or other jewelry on affected arm.
Rationale: Reduces pressure on compromised tissues, which may improve circulation and healing, and minimize lymphedema.
10. Administer antibiotics, as indicated.
Rationale: Provides prophylaxis to treat specific infection and enhance healing.