Diagnosis
Impaired skin/tissue integrity
related to postoperative
recovery period as evidenced by
disruption of skin surfaces and
tissues
Acute postoperative pain
Rank Justification
1 The skin is the body’s outermost defense system
that keeps pathogens from entering and causing
illness. When the skin is compromised due to
cuts, abrasions, ulcers, incisions, and wounds, it
allows bacteria to enter, causing infections. The
nursing care plan, therapeutic nursing
interventions, and actions will focus on different
aspects of client care, including optimizing
cardiac function, managing symptoms,
promoting client and caregiver education, and
preventing complications. We must assess the
site of impaired tissue integrity and its
condition. Assess the characteristics of the
wound, including type, location, color, size
(length, width, and depth), drainage, and odor.
Assess changes in body temperature, specifically
increased body temperature. Assess the client’s
level of pain. Monitor the site of impaired tissue
integrity at least once daily for color changes,
redness, swelling, warmth, pain, or other signs
of infection. Monitor the status and condition of
the skin around the wound. Provide wound care
as needed. Provide medications as ordered. This
promotes the cooperation of the client in their
own medical situation. Because nonadherence
to care and medication can have rapid and
profound adverse effects on the client's status,
close observation and follow-up are important
aspects of care that may cause impaired skin
integrity.
2 Acute postoperative pain is one of the more
distressing aspects of surgery. It is a complex
physiological reaction to tissue injury that
manifests in autonomic, psychological, and
behavioral responses. Postoperative pain is an
anticipated and temporary (2–5 days) increase
in background pain that occurs after burn
excision or grafting procedures and is most
commonly the result of increased pain from
newly created wounds at the skin graft
harvesting site. Therapeutic nursing
interventions and actions will focus on different
aspects of client care, including optimizing
cardiac function, managing symptoms,
promoting client and caregiver education, and
preventing complications. We must perform a
comprehensive assessment of pain. Determine

Activity intolerance related to
acute postoperative pain as
evidenced by dizziness and
weakness
the location, characteristics, onset, duration,
frequency, quality, and severity of pain via
assessment. Assess the location of the pain by
asking them to point to the site that is
discomforting. Perform a history-based
assessment of pain. Determine the client’s
perception of pain. Pain should be screened
every time vital signs are evaluated. Determine
factors that alleviate pain. Provide
pharmacologic pain management as ordered.
3 Activity intolerance is a state in which an
individual has insufficient physiological or
psychological energy to endure or complete
necessary or desired daily activities. Numerous
factors lead to activity intolerance. Improper
oxygen balance, pain, sleep deprivation,
depression, low motivation, and severe stress,
medication side effects, extended bed rest, a
sedentary lifestyle, and restrictions to healthy
activity levels also lead to activity intolerance.
Therapeutic nursing interventions and actions
will focus on different aspects of client care,
including optimizing cardiac function, managing
symptoms, promoting client and caregiver
education, and preventing complications. We
must assess the patient’s present level of
activity and tolerance to activity. Assess the
patient’s vital signs. Assess the underlying cause
of activity intolerance. Review medication list.
Assess nutritional status. Assess potential need
for assistive devices with activity. Assess skin
integrity frequently. Monitor and evaluate sleep
quality, length, and patterns. Identify and
address potential sleep deficiencies to maximize
recovery/activity progress while reducing the
opportunities for errors to occur.