NCP: Impaired Skin Integrity

ASSESSMENT
Cues: pain at the
surgical site with
pain score of: ___
Clues:
- S/p laparoscopic
cholecystectomy
or open
cholecystectomy.
(planned surgical
procedure is
laparoscopic
cholecystectomy
possible open
cholecystectomy)
-Disruption of skin
layers.
-Invasion of body
structures.

NURSING
RATIONALE
DIAGNOSIS
Impaired skin
In laparoscopic
integrity related to
cholecystectomy,
surgical procedure. gallbladder is
removed through a
small incision or
puncture made
through abdominal
wall. The fiberoptic
scope is inserted
through the small
umbilical incision
and then several
additional
punctures or small
incisions are made
in the abdominal
wall to introduce
other surgical
instruments into
the operative field.
On the other hand,
in open
cholecystectomy,
gallbladder is
removed through
an abdominal
incision (usually
right subcostal)
after the cystic
duct and artery are
ligated.

OBJECTIVES
After 4.5 hours of
nursing
interventions, the
patient will be able
to:
Short Term:
Maintain optimal
nutrition and
physical being.
Participate in
prevention
measures and
treatment
program.
Verbalize
feelings of
increased selfesteem and
ability to
manage
situation.
Long Term:
Display timely
healing of
surgical wound
without
complication.

NURSING
INTERVENTIONS
Independent:
1.Note skin color,
texture and
turgor.
2.Palpate surgical
incision for size,
shape,
consistency,
texture,
temperature and
hydration and
determine skin
layer
involvement.
3.Inspect
surrounding skin
for erythema or
inflammation
and note odors
emitted from the
surgical incision.
4.Inspect skin on
daily basis,
describing
wound
characteristics
and changes
observed.
5.Periodically
measure wound
and observe for
complications
like infection and
dehiscence.
6.Keep the area
clean and dry,
carefully dress

RATIONALE
To assess extent
of involvement/
injury.
To determine
degree and
depth of injury or
damage to
integumentary
system

To assess for
complications
and infection.

To promote
optimal wound
healing.

To monitor
progress of
wound healing.

To assist bodys
natural process
of repair.

EVALUATION
After 4.5 hours
of nursing
interventions,
the goals were
met. The patient
was able to
maintain optimal
nutrition and
physical being.
She was able to
participate in
prevention
measures and
treatment
program as
evidence by her
cooperation. And
was able to
verbalize
feelings of
increased selfesteem and
ability to manage
situation by
demonstrating a
positive attitude.

NCP: Impaired Skin Integrity

wounds, support
incision (e.g.
splinting when
coughing),
prevent
infection, and
stimulate
circulation to
surrounding
areas.
7.Use appropriate
barrier dressings
and wound
coverings.
8.Remove wet and
wrinkled
dressing/ linens
promptly.
9.Encourage early
ambulation or
mobilization.
10.
Provide
optimum
nutrition.
Dependent:
Administer
prescribed pain
medications,
antibiotics and
other
medications.

To protect the
wound and
surrounding
tissues.
Moisture
potentiates skin
breakdown.
To promote
circulation and
reduces risks
associated with
immobility.
To aid in skin
and tissue
healing and to
maintain general
good health.
To relieve pain
and prevent
infection and
complications.