NURSING DIAGNOSIS: Actual/Risk for impaired tissue integrity

related to:
  1. disruption of tissue associated with the surgical procedure;
  2. delayed wound healing associated with factors such as decreased nutritional status and inadequate blood supply to wound area;
  3. irritation of skin associated with contact with wound drainage, pressure from tubes, and use of tape.
Desired Outcome
The client will experience normal healing of surgical wound(s) as evidenced by:
  1. gradual reduction in periwound swelling and redness
  2. presence of granulation tissue if healing is by secondary intention
  3. intact, approximated wound edges if healing is by primary intention.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of impaired wound healing (e.g. increasing periwound swelling and redness, pale or necrotic tissue in wounds healing by secondary intention, separation of wound edges in wounds healing by primary intention).
  2. Implement measures to promote wound healing:
    1. perform actions to maintain an adequate nutritional status (see Diagnosis 5, action d)
    2. perform actions to maintain adequate circulation to wound area:
      1. implement measures to maintain adequate tissue perfusion (see Diagnosis 1, action b)
      2. do not apply dressings tightly unless ordered (excessive pressure impairs circulation to the area)
    3. perform actions to protect the wound from mechanical injury:
      1. ensure that dressings are secure enough to keep them from rubbing and irritating wound
      2. carefully remove tape and dressings when performing wound care
      3. remind client to keep hands away from wound area
      4. implement measures to prevent falls (see Diagnosis 18, action a)
    4. perform actions to decrease stress on wound area:
      1. instruct and assist client to support the involved area when moving
      2. instruct and assist client to splint abdominal and chest wounds when coughing
      3. apply an abdominal binder during periods of activity if ordered for additional support following abdominal surgery
      4. implement measures to reduce the accumulation of gas and fluid in the gastrointestinal tract (see Diagnosis 7, action b) in clients who have had abdominal surgery
      5. implement measures to prevent nausea and vomiting (see Diagnosis 8, action b) in clients who have had chest, back, or abdominal surgery
    5. perform actions to prevent wound infection (see Diagnosis 17).
  3. If signs and symptoms of impaired wound healing occur:
    1. perform or assist with wound care (e.g. debridement, packing, irrigation) as ordered
    2. prepare client for surgical revision of the wound if planned.
Desired Outcome
The client will maintain tissue integrity in areas in contact with wound drainage, tape, and tubings as evidenced by:
  1. absence of redness and irritation
  2. no skin breakdown.
Nursing Actions and Selected Purposes/Rationales
  1. Inspect skin areas that are in contact with wound drainage, tape, and tubings for signs of irritation and breakdown.
  2. Implement measures to prevent tissue irritation and breakdown in areas in contact with wound drainage, tape, and tubings:
    1. perform actions to prevent wound drainage from contacting or remaining on skin:
      1. inspect dressings, wounds, and areas around drains and puncture sites; cleanse skin and change dressings when appropriate
      2. maintain patency of drainage tubes to decrease risk of leakage around the tubes
      3. apply a collection device over drains and incisions that are draining continuously and/or copiously
      4. apply a protective barrier product to skin that is likely to be in frequent contact with drainage
    2. when positioning client, ensure that he/she is not lying on tubings (pressure on the skin can compromise circulation to that area; in addition, if a drainage tubing is occluded, there is an increased risk for leakage of drainage around the tube)
    3. anchor all tubings securely to prevent excessive movement of tubes against tissues
    4. apply a water-soluble lubricant to external nares every 2-4 hours to decrease irritation from nasogastric tube and nasal airway or cannula
    5. perform actions to decrease skin irritation resulting from the use of tape:
      1. use only necessary amount of tape
      2. use hypoallergenic tape whenever possible
      3. apply skin sealant or barrier before applying tape if indicated
      4. use Montgomery straps or tubular netting to avoid repeated application and removal of tape if frequent dressing changes are anticipated
      5. when removing tape, pull it in the direction of hair growth; use adhesive solvents if necessary.
  3. If tissue breakdown occurs:
    1. notify appropriate health care provider (e.g. physician, wound care specialist)
    2. perform care of involved areas as ordered or per standard hospital procedure.