Impaired Skin Integrity
Impaired Skin Integrity
Impaired Skin Integrity
Cues
Subjective:
Objective:
T: 36.9
PR: 89
RR: 19
BP: 120/80
(+) Surgical
incision (L)
mid axillary
line.
No
exudates,
itchiness,
and redness
noted.
Diagnosis
Impaired skin /
tissue integrity
related to
mechanical
interruption of
skin (presence
of surgical
wound)
secondary to
pneumonecto
my.
Background
Knowledge
Planning
Intervention
Rationale
To monitor patients
progress
Reinforced initial
dressing and change
as indicated. Use
strict aseptic
techniques.
Inspected wound
regularly, noting
characteristics and
integrity. Note
patients at risk for
delayed healing.
Early recognition of
delayed healing or
developing
complications may
prevent a more
serious situation.
Elevated operative
area as appropriate.
Promotes venous
return and limits
edema formation.
Note: Elevation in
presence of venous
insufficiency may be
detrimental.
Evaluation
After 2-4 hours
immediate post
operative nursing
care the clientl
manifesed intact
skin integrity as
evidenced by:
1.) Abscence of
inflammation
,redness ,purulent
discharges on skin
or operative site
2.) Vitals signs
remained in normal
range. T: 36.8
PR:91 RR. 20 BP:
120/80
Prevents
contamination of
wound.
Reduces skin
contaminants; aids
in removal of
drainage or exudate.
Promoted proper
deep breathing and
coughing exercises.
Assess first LOC
To prevent
complications
(atelectasis)
Dependent:
Administered
antibacterial drugs as
prescribed by the
physician
Prevent infection