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    Impaired Skin Integrity

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    Sharewin Pulido
    1.) The patient underwent a pneumonectomy and had a surgical incision on the left mid axillary line with no exudates, itchiness, or redness noted. 2.) The patient's vital signs were within normal limits and their diagnosis was impaired skin/tissue integrity related to the surgical wound. 3.) The nursing care plan was to monitor the patient's vital signs and intake/output, reinforce dressings and inspect the wound regularly to promote healing and prevent infection.

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    Impaired Skin Integrity

    Uploaded by

    Sharewin Pulido
    500 views2 pages
    1.) The patient underwent a pneumonectomy and had a surgical incision on the left mid axillary line with no exudates, itchiness, or redness noted. 2.) The patient's vital signs were within normal limits and their diagnosis was impaired skin/tissue integrity related to the surgical wound. 3.) The nursing care plan was to monitor the patient's vital signs and intake/output, reinforce dressings and inspect the wound regularly to promote healing and prevent infection.

    Original Description:

    Nursing Care Plan for post op patients

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    1.) The patient underwent a pneumonectomy and had a surgical incision on the left mid axillary line with no exudates, itchiness, or redness noted. 2.) The patient's vital signs were within normal limits and their diagnosis was impaired skin/tissue integrity related to the surgical wound. 3.) The nursing care plan was to monitor the patient's vital signs and intake/output, reinforce dressings and inspect the wound regularly to promote healing and prevent infection.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    500 views2 pages

    Impaired Skin Integrity

    Uploaded by

    Sharewin Pulido
    1.) The patient underwent a pneumonectomy and had a surgical incision on the left mid axillary line with no exudates, itchiness, or redness noted. 2.) The patient's vital signs were within normal limits and their diagnosis was impaired skin/tissue integrity related to the surgical wound. 3.) The nursing care plan was to monitor the patient's vital signs and intake/output, reinforce dressings and inspect the wound regularly to promote healing and prevent infection.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    Nursing Care Plan (Post-operative Care)

    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

    Within our 2Due to


    4 hours
    patients
    immediate
    recent surgery post
    operative
    nursing care
    Tissue trauma the client will
    on surgical
    manifest
    incisicion site intact skin
    integrity as
    evidenced
    Impaired skin by:
    /tissue
    integrity
    1.) Abscence
    of
    inflammation
    ,redness
    ,purulent
    discharges
    on skin or
    operative
    site
    2.) Vitals
    signs wil
    remain in
    normal
    range.

    Intervention

    Rationale

    Monitored vital signs.

    To monitor patients
    progress

    Monitored intake and


    output.

    To assess risk for


    hypovolemic shock

    Reinforced initial
    dressing and change
    as indicated. Use
    strict aseptic
    techniques.

    Protects wound from


    mechanical injury
    and contamination.
    Prevents
    accumulation of
    fluids that may
    cause excoriation.

    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

    Caution patient not to


    touch wound.

    Prevents
    contamination of
    wound.

    Cleanse skin surface


    (if needed) with
    diluted hydrogen
    peroxide solution, or
    running water and
    mild soap after
    incision is sealed.

    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

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