Impaired Skin/Tissue Integrity | Nursing Care Plan for Cholecystectomy

Nursing diagnosis: related to Chemical substance—bile, stasis of secretions, Altered nutritional state (obesity) or metabolic state, Invasion of body structure—T-tube punctures or incision

Possibly evidenced by
Disruption of skin or subcutaneous tissues

Desired Outcomes/Evaluation Criteria—Client Will
Wound Healing: Primary/Secondary Intention
Achieve timely wound healing without complications.
Demonstrate behaviors to promote healing and prevent skin breakdown.

Nursing intervention with rationale:
1. Observe the color and character of NG and T-tube drainage.
Rationale: Initially, drainage may contain blood and blood-stained fluid, normally changing to greenish-brown (bile color) after the first several hours.

2. Maintain T-tube in closed collection system.
Rationale: Prevents skin irritation and reduces risk of contamination.

3. Check the T-tube and incisional drains; make sure they are free flowing.
Rationale: T-tube may remain in common bile duct for 7 to 10 days to remove retained tiny stones and gravel. Incision site drains are used to remove any accumulated fluid and bile. Correct positioning prevents backup of the bile in the operative area.

4. Anchor drainage tube, allowing sufficient tubing to permit free turning and avoid kinks and twists.
Rationale: Avoids dislodging tube and occlusion of the lumen.

5. Change dressings often initially, then as needed. Clean the skin with soap and water. Use sterile petroleum jelly gauze, zinc oxide, or karaya powder around the incision.
Rationale: Keeps the skin around the incision clean and provides a barrier to protect skin from excoriation from bile leaking outside of T-tube.

6. Apply Montgomery straps for client who had open cholecystectomy.
Rationale: Facilitates frequent dressing changes and minimizes skin trauma.

7. Use a disposable ostomy bag over a stab wound drain.
Rationale: Ostomy appliance may be used to collect heavy drainage for more accurate measurement of output and protection of the skin.

8. Place client in low- or semi-Fowler’s position.
Rationale: Facilitates drainage of bile.

9. Monitor puncture sites (three to five) if endoscopic procedure is done.
Rationale: These areas may bleed, or staples and Steri-Strips may loosen at puncture wound sites.

10. Observe for hiccups, abdominal distention, or other signs of peritonitis such as rigid abdomen, fever, and severe right upper quadrant (RUQ) abdominal pain suggesting pancreatitis.
Rationale: Dislodgment of the T-tube can result in diaphragmatic irritation or more serious complications if bile drains into abdomen or pancreatic duct is obstructed.