Nursing Diagnosis for Cardiac Surgery | Impaired Skin Integrity

Nursing diagnosis: Impaired Skin Integrity related to Surgical incisions, puncture wounds

Possibly evidenced by

Disruption of skin surface

Desired Outcomes/Evaluation Criteria—Client Will

Wound Healing: Primary Intention

Demonstrate behaviors and techniques to promote healing and prevent complications.

Nursing care plan intervention with rationale:

1. Inspect all incisions. Evaluate healing progress. Review expectations for healing with client.

Rationale: Healing begins immediately, but complete healing takes time. Chest incision heals first (minimal muscle tissue), but donor site incision requires more time (more muscle tissue, longer incision, slower circulation). As healing progresses, the incision lines may appear dry, with crusty scabs. Underlying tissue may look bruised and feel tense, warm, and lumpy, suggesting resolving hematoma.

2. Suggest wearing soft cotton shirts and loose-fitting clothing, leaving incisions open to air as much as possible, covering and padding portion of incisions as necessary.

Rationale: Reduces suture line irritation and pressure from clothing. Leaving incisions open to air promotes healing process and may reduce risk of infection.

3. Have client shower in warm water, washing incisions gently. Instruct client to avoid tub baths until approved by physician.

Rationale: Keeps incision clean and promotes circulation and healing. Note: Climbing out of tub requires use of arms and pectoral muscles, which can put undue stress on sternotomy.

4. Encourage ankle exercises and elevation of legs when sitting in chair.

Rationale: Promotes circulation and reduces edema to improve tissue healing.

5. Review normal signs of healing, such as itching along wound line, bruising, slight redness, and scabbing.

Rationale: Helps client understand expected progression of healing and recognize signs of complications or nonhealing requiring further evaluation and intervention.

6. Instruct to watch for and report to physician places in incision that do not heal; reopening of healed incision; bloody or purulent drainage; localized area that is swollen with redness, feels increasingly painful, and is hot to touch; and temperature greater than 101.5 F (38.6 C) for longer than 24 hours.

Rationale: Incisional problems rank second behind chest pain as cause of readmission after CABG. The incidence of sternal infection (mediastinitis) following coronary artery bypass graft surgery is less than 5% (Keib, 2006); however, this devastating complication results in significant mortality and morbidity and financial and care burden.

7. Promote adequate nutritional and fluid intake.

Rationale: Helps maintain good circulating volume for tissue perfusion and meets cellular energy requirements to facilitate tissue regeneration and healing process.

8. Obtain specimen of wound drainage, as indicated. Administer antimicrobials and local treatments, as indicated.

Rationale: If infection occurs, local and systemic treatments may be required.