Impaired Skin/Tissue Integrity

Nursing diagnosis: impaired Skin/Tissue Integrity related to Invasion of body structure, such as with perineal resection, Stasis of secretions or drainage, Altered circulation, edema; malnutrition

Possibly evidenced by
Disruption of skin and tissue—presence of incision and sutures, drains

Desired Outcomes/Evaluation Criteria—Client Will
Wound Healing: Primary Intention
Achieve timely wound healing free of signs of infection.

Nursing intervention with rationale:
1. Observe wounds, noting characteristics of drainage.
Rationale: Postoperative hemorrhage is most likely to occur during the first 48 hours, whereas infection may develop at any time. Depending on type of wound closure, complete healing may take 6 to 8 months.

2. Change dressings as needed.
Rationale: Large amounts of serous drainage require that dressings be changed frequently to reduce skin irritation and potential for infection.

3. Encourage side-lying position with head elevated. Avoid prolonged sitting.
Rationale: Promotes drainage from perineal wound/drains, reducing risk of pooling. Prolonged sitting increases perineal pressure, reducing circulation to wound, and may delay healing.

4. Irrigate wound as indicated, using normal saline (NS), diluted hydrogen peroxide, or antibiotic solution.
Rational: May be required to treat preoperative inflammation, infection, or intraoperative contamination.

5. Provide sitz baths.
Rationale: Promotes cleanliness and facilitates healing, especially after packing is removed—usually day 3 to 5.