Nursing diagnosis: impaired skin integrity related to mechanical interruption of skin and tissues; altered circulation, effects of medication, accumulation of drainage, altered metabolic state
Possibly evidenced by
Disruption of skin surface/layers and tissues
Desired Outcomes/Evaluation Criteria—Client Will
Wound Healing: Primary Intention
Achieve timely wound healing.
Knowledge: Treatment Regimen
Demonstrate behaviors or techniques to promote healing and prevent complications.
Nursing intervention with rationale:
1. Reinforce initial dressing or change, as indicated. Use strict aseptic techniques.
Rationale: Protects wound from mechanical injury and contamination. Prevents accumulation of fluids that may cause excoriation. Note: Studies suggest clean techniques may be sufficient, but additional research is required before protocols are revised.
2. Gently remove tape in direction of hair growth and dressings when changing.
Rationale: Reduces risk of skin trauma and disruption of wound.
3. Apply skin sealants or barriers before tape, if needed. Use hypoallergenic tape, Montgomery straps, or elastic netting for dressings requiring frequent changing.
Rationale: Reduces potential for skin trauma or abrasions and provides additional protection for delicate skin and tissues.
4. Check tension of dressings. Apply tape at center of incision to outer margin of dressing. Avoid wrapping tape around extremity.
Rationale: Prevents tape skin abrasions. Wrapping tape can impair or occlude circulation to wound and to distal portion of extremity.
5. Inspect incision regularly, noting characteristics and integrity. Note clients at risk for delayed healing such as presence of COPD, anemia, obesity, malnutrition, DM, hematoma formation, vomiting, ETOH (ethyl alcohol) withdrawal; use of steroid therapy; and advanced age.
Rationale: Early recognition of delayed healing or developing complications may prevent a more serious situation. Incisions may heal more slowly in clients with comorbidity, or the elderly in whom reduced cardiac output decreases capillary blood flow.
6. Assess amounts and characteristics of drainage.
Rationale: Decreasing drainage suggests evolution of healing process, whereas continued drainage or presence of bloody or odoriferous exudate suggests complications, which may include hemorrhage, infection, and fistula formation.
7. Maintain patency of drainage tubes; apply collection bag over drains or incisions in presence of copious or caustic drainage.
Rationale: Facilitates approximation of wound edges; reduces risk of infection and chemical injury to skin and tissues.
8. Splint abdominal and chest incisions or area with pillow or pad during coughing and movement.
Rationale: Equalizes pressure on the wound, minimizing risk of dehiscence— especially important during stage I healing during the first 3 to 4 days—and for incisions closed with adhesives.
9. Cleanse skin surface, if needed, with diluted hydrogen peroxide solution, or running water and mild soap after incision is sealed.
Rationale: Reduces skin contaminants; aids in removal of drainage or exudate.
10. Monitor and maintain dressings, whether hydrogel, vacuum dressing, or other types.
Rationale: May be used to hasten healing in large, draining wound or fistula, to increase client comfort, and to reduce frequency of dressing changes. Also allows drainage to be measured more accurately and analyzed for pH and electrolyte content, as appropriate.