Impaired skin integrity related to surgical removal of skin/tissue secondary to surgery Assessment Nursing Scientific Objectives Nursing Diagnosis

Explanation Interventions S= Impaired skin Mastectomy, SHORT TERM: > establish O= the patient integrity related like any other After 4 hours of rapport may manifest: to surgical surgical nursing >Presence of removal of procedures, interventions, surgical wound skin/tissue includes the patient will > monitor and on the breast secondary to invasion of the participate in record vital sign where incision surgery as inside body, prevention > assess incision was made evidence by specifically the measures and site taking note of > presence of disruption of skin and treatment size, color, Pain skin surface subcutaneous program location, > Numbness of and layers. area. Upon temperature, surrounding incision, there LONG TERM: texture, areas will be After 1-2 days consistency of > Disruption of impairment of of nursing wound/ lesion if skin surface the skin interventions, possible > Redness integrity the patient will > inspect > Itchiness causing be able to surrounding skin >Poor capillary damage, display for erythema, refill impairment of progressive indurations, skin circulation improvement in maceration and sensation wound healing. > assess for and pain in the odors and drains incision site. coming out from An incision is the skin/ area of made in the injury breast. The underlying > inspect skin on muscles are a daily basis, opened to describing lesions expose the and changes

Rationale > to gain the trust and cooperation of the client > to obtain baseline data > to provide comparative baseline data

Expected Outcomes SHORT TERM: The patient shall participate in prevention measures and treatment program LONG TERM: The patient shall be able to display progressive improvement in wound healing.

> to assess extent of involvement

> to assess early progression of wound healing, development of hemorrhage or infection > to promote timely intervention/revision of plan of care

tumor beneath the breast. The surgeon then removes part or the entire breast while taking great care not to injure nearby blood vessels or nerves. The muscles are then repaired and the skin incision is closed with sutures that will either absorb or be removed soon after the operation. The actual incising of the skin is seen as impairment in the skins integrity.

observed > keep the area clean/dry, carefully dress wounds, support incision, and prevent infection > use appropriate wound coverings

> to assist bodys natural process of repair

> protect the wound and/or surrounding tissue > encourage an > to aid in timely increase in protein wound healing for and calorie intake the patient > encourage > to prevent fatigue adequate rest and sleep > encourage early > to promote ambulation and circulation and mobilization reduce risks associated with immobility > provide position > to prevent bed changes ulcers from > practice aseptic occurring technique in > to reduce risk of cleansing/dressing cross-contamination and medicating lesions > instruct proper disposal of soiled > to prevent spread dressing of infectious agent