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;
  4. excessive or prolonged pressure on tissues from compression dressing, knee immobilizer, or CPM machine;
  5. damage to the skin and/or subcutaneous tissue associated with prolonged pressure on tissues, friction, and shearing while mobility is decreased.
Desired Outcome
The client will experience normal healing of the surgical wound (see Standardized Postoperative Care Plan, Diagnosis 10, for outcome criteria).
Nursing Actions and Selected Purposes/Rationales
  1. Refer to Standardized Postoperative Care Plan, Diagnosis 10, for measures related to assessment and promotion of wound healing.
Desired Outcome
The client will maintain tissue integrity as evidenced by:
  1. absence of redness and irritation
  2. no skin breakdown.
Nursing Actions and Selected Purposes/Rationales
  1. Inspect the following areas for pallor, redness, and breakdown:
    1. skin in contact with wound drainage, tape, and tubings
    2. back, coccyx, and buttocks
    3. elbows and heels
    4. areas at edges of compression dressing or knee immobilizer
    5. areas in contact with CPM machine.
  2. Refer to Standardized Postoperative Care Plan, Diagnosis 10, for measures related to prevention of tissue irritation and breakdown in areas in contact with wound drainage, tubings, and tape.
  3. Implement measures to prevent tissue breakdown associated with decreased mobility:
    1. position client properly; use pressure-reducing or pressure-relieving devices (e.g. pillows, alternating pressure mattress) if indicated
    2. instruct client to use overhead trapeze to lift self and shift weight at least every 30 minutes
    3. gently massage around reddened areas at least every 2 hours
    4. apply a thin layer of a dry lubricant such as powder or cornstarch to bottom sheet or skin and to opposing skin surfaces (e.g. axillae) if indicated to reduce friction
    5. lift and move client carefully using a turn sheet and adequate assistance
    6. perform actions to keep client from sliding down in bed (e.g. limit length of time client is in semi-Fowler's position to 30 minute intervals) in order to reduce the risk of skin surface abrasion and shearing
    7. turn client at least every 2 hours when not in CPM machine; keep pillows between legs and operative knee extended
    8. keep client's skin clean
    9. keep bed linens dry and wrinkle-free
    10. increase activity as allowed and tolerated.
  4. Implement measures to prevent irritation and breakdown on elbows and heels:
    1. massage elbows and heels with lotion frequently
    2. encourage client to use overhead trapeze to move self rather than pushing up with heel and elbows
    3. provide elbow and heel protectors if indicated.
  5. Implement measures to prevent tissue breakdown in areas in contact with the compression dressing, knee immobilizer, and CPM machine:
    1. assess for and report tightness of the dressing or reports of a burning sensation under the dressing or knee immobilizer
    2. loosen straps on knee immobilizer if it appears to be too tight
    3. apply cornstarch to skin under immobilizer in order to reduce friction and subsequent skin irritation
    4. keep dressing dry
    5. position the operative extremity so that the knee immobilizer and CPM machine are not causing excessive pressure on any area
    6. make sure CPM machine is padded adequately
    7. instruct client to refrain from inserting anything inside the dressing or knee immobilizer.
  6. 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.