Impaired Skin Integrity 65

c

!-disruption of skin surface -destruction f skin layers





" # Impaired skin integrity was due to the client·s tissue trauma on the surgical incision site from his recent surgery caused by small bowel obstruction.

# By the end of the shift, the client will develop and maintain optimal conditions for wound healing.

$ # The skin is a barrier to infectious agents; however, any break in the skin can readily serve as a portal of entry putting the individual at risk for potential infections. (Fundamentals of Nursing by Kozier, et.al., 7th edition, page 633)

# 1. After 30 minutes, the nurse will be able to assess the extent of involvement or injury.

c

1. Note skin color, texture, and turgor. 2. Palpate skin lesions for size, shape, consistency, texture, temperature, and hydration. 3. Determine degree or depth of injury or damage to skin. 4. Measure length, width, depth of wound. 5. Inspect surrounding skin for erythema, induration, and maceration. 6. Note odors



-To document status and provide baseline for future comparisons. c c

The client developed and maintained optimal conditions for wound healing as evidenced by responses to interventions and teaching and actions performed and gradual healing of his wound.

emitted from the wound. 1. Inspect skin, describing wound characteristics and changes observed. 2. Remeasure wound and observe for complications.

2. After the shift, the nurse will be able to assist the client with correcting and minimizing condition and promote optimal healing of wound.

3. Use appropriate dressings, wound coverings, drainage appliances for open or draining wounds. 4. Encourage early ambulation.



-To monitor progress of wound healing. c c -To protect the wound and surrounding tissues. c c -Promotes circulation and reduces risks associated with immobility. c c