ASSESSMENT S O surgical incision with sutures -presence of T-tube

PLANNING "ithin # hours of nursing intervention the patient$s surgical wound will be able to heal without complication!

DIAGNOSIS Impaired Skin Integrity related to surgical incision SCIENTIFIC EXPLANATION From the surgical intervention done, which involves cutting or penetration of skin surface and layers there is in ury or trauma wherein tissue is inflicted!

INTERVENTION %ssess skin color and temperature in operative area! R: skin should be pink or similar to color in surrounding the skin. Cyanosis will indicate venous congestion which will lead to tissue necrosis. & 'rotect skin flaps and suture lines from tension or pressure! 'rovide pillow and instruct the patient to support his abdomen! R: tension on suture lines will cause tissue injury. & (onitor bloody drainage from surgical site! R: bloody drainage usually declines steadily after first 24 hours. Frank bleeding indicates problem. & 'rovide meticulous skin care, pay particular attention to skin folds common in the very obese client! R: oisture or e!coriation enhances growth of bacteria that can lead to postoperative infection & 'rovide foam, water, or air mattress, as indicated! R: Reduces skin pressure and enhances circulation

EXPECTED OUTCOME %fter # hours of nursing intervention the patient$s surgical wound will be able to heal without complication!

& )ncourage to eat protein rich foods such as egg whites, cheese and fish! R: to promote healing and help repair the damaged tissue &Observe incisions periodically, noting appro*imation of wound edges, hematoma formation and resolution, and presence of bleeding and drainage! R: "erifies status of healing# provides for early detection of developing complications re$uiring prompt evaluation and influencing choice of interventions.