c



 
 
  c
 
 


 


 " 
# 
# The client



 Impaired skin By the end of the developed and


 integrity was due to shift, the client will maintained optimal
  the client·s tissue develop and conditions for wound
  trauma on the maintain optimal healing as
 
 surgical incision site conditions for wound evidenced by
 

  from his recent healing. responses to
 surgery caused by interventions and
!-disruption of small bowel  # teaching and actions
skin surface obstruction. 1. After 30 minutes, 1. Note skin color, -To document status performed and
-destruction f the nurse will be texture, and turgor. and provide gradual healing of
skin layers $

# able to assess the 2. Palpate skin baseline for future his wound.
The skin is a barrier extent of lesions for size, comparisons.
to infectious agents; involvement or shape, consistency, c c
 

however, any break injury. texture, 

in the skin can temperature, and
readily serve as a hydration.
portal of entry 3. Determine
putting the degree or depth of
individual at risk for injury or damage to
potential infections. skin.
(Fundamentals of 4. Measure length,
Nursing by Kozier, width, depth of
et.al., 7th edition, wound.
page 633) 5. Inspect
surrounding skin for
erythema,
induration, and
maceration.
6. Note odors

2. After the shift, the
nurse will be able to
assist the client with
correcting and
minimizing condition
and promote
optimal healing of

emitted from the
wound.
1. Inspect skin,
describing wound
characteristics and
changes observed. -To monitor progress
2. Remeasure wound of wound healing.
and observe for c c
 
wound. complications. 
-To protect the
wound and
3. Use appropriate surrounding tissues.
dressings, wound c c
 

coverings, drainage 
appliances for open -Promotes circulation
or draining wounds. and reduces risks
4. Encourage early associated with
ambulation. immobility.
c c