N Impaired Skin Integrity 1k5k72

N: Impaired Skin Integrity ASSESSMENT Cues: pain at the surgical site with pain score of: ___ Clues: - S/p laparoscopic cholecystectomy or open cholecystectomy. (planned surgical procedure is laparoscopic cholecystectomy possible open cholecystectomy) -Disruption of skin layers. -Invasion of body structures.

NURSING RATIONALE DIAGNOSIS Impaired skin In laparoscopic integrity related to cholecystectomy, surgical procedure. gallbladder is removed through a small incision or puncture made through abdominal wall. The fiberoptic scope is inserted through the small umbilical incision and then several additional punctures or small incisions are made in the abdominal wall to introduce other surgical instruments into the operative field. On the other hand, in open cholecystectomy, gallbladder is removed through an abdominal incision (usually right subcostal) after the cystic duct and artery are ligated.

OBJECTIVES After 4.5 hours of nursing interventions, the patient will be able to: Short Term:  Maintain optimal nutrition and physical being.  Participate in prevention measures and treatment program.  Verbalize feelings of increased selfesteem and ability to manage situation. Long Term:  Display timely healing of surgical wound without complication.

NURSING INTERVENTIONS Independent: 1.Note skin color, texture and turgor. 2.Palpate surgical incision for size, shape, consistency, texture, temperature and hydration and determine skin layer involvement. 3.Inspect surrounding skin for erythema or inflammation and note odors emitted from the surgical incision. 4.Inspect skin on daily basis, describing wound characteristics and changes observed. 5.Periodically measure wound and observe for complications like infection and dehiscence. 6.Keep the area clean and dry, carefully dress

RATIONALE  To assess extent of involvement/ injury.  To determine degree and depth of injury or damage to integumentary system

 To assess for complications and infection.

 To promote optimal wound healing.

 To monitor progress of wound healing.

 To assist body’s natural process of repair.

EVALUATION After 4.5 hours of nursing interventions, the goals were met. The patient was able to maintain optimal nutrition and physical being. She was able to participate in prevention measures and treatment program as evidence by her cooperation. And was able to verbalize feelings of increased selfesteem and ability to manage situation by demonstrating a positive attitude.

N: Impaired Skin Integrity wounds, incision (e.g. splinting when coughing), prevent infection, and stimulate circulation to surrounding areas. 7.Use appropriate barrier dressings and wound coverings. 8.Remove wet and wrinkled dressing/ linens promptly. 9.Encourage early ambulation or mobilization. 10. Provide optimum nutrition. Dependent:  ister prescribed pain medications, antibiotics and other medications.

 To protect the wound and surrounding tissues.  Moisture potentiates skin breakdown.  To promote circulation and reduces risks associated with immobility.  To aid in skin and tissue healing and to maintain general good health.  To relieve pain and prevent infection and complications.