Impaired Tissue Integrity Care Plan | Nursing Diagnosis Writing Services
Impaired tissue integrity occurs when an individual suffers damage to the mucous membrane. Also, the damage may occur to the skin, cornea, subcutaneous tissues, which are the first line of protection against threats from the external environment.
Even though these defenses offer sufficient protection to the body against any threat, some factors may still cause impairment or a break to these defenses, thereby causing impairment of tissue integrity.
Some of the common causes include physical trauma like a car accident, cuts, sports injury, blunt trauma, and more. Others are thermal factors like burns, chemical injury from an adverse drug reaction, infection, fluid imbalances, nutritional imbalance, and altered circulation like pressure ulcers.
Impaired tissue integrity is usually repaired by the body: When there is a situation that the body doesn’t repair the broken tissues but replaces the impaired tissue with connective tissue. If the impaired tissue integrity is left untreated, it can cause local or systemic infection and finally lead to necrosis. A nurse will need to write a detailed nursing care plan for such patients.
Impaired Tissue Integrity Care Plan Diagnosis
Impaired tissue integrity is characterized by these signs and symptoms:
- Tenderness and heat on the affected tissue
- Protectiveness toward the affected area
- Damaged or destroyed tissues like cornea, integumentary, mucous membranes, subcutaneous.
- Swelling around the impaired area
- Localized pain
Impaired Tissue Integrity Care Plan Goals and Outcomes
A care plan for impaired tissue integrity provides a clear roadmap for the caregiver to help the patient in attaining the following goals and outcomes:
- Diminish in size of the wound and increased granulation
- Healing of the wound
- Absence of irritation, redness on the tissue
- Healing of the wound
- Lack of skin breaks down
- The patient reports a change of sensation on the impaired tissues
- The patient offers suggestions on the right measures for caring for and healing the tissue, which may include wound care.
Nursing Assessment for Impaired Tissue Integrity
Assessment is needed to recognize possible problems that can lead to impaired tissue integrity and also identify any experience that may emerge during nursing care. The following factors can help the nurse in assessing the patient’s impaired tissue integrity state.
- Assess the etiology such as an acute or chronic wound, dermatological lesion, burn, pressure ulcer, leg ulcer: Before the assessment of a wound, etiology is essential to proper identification of caregiving interventions.
- Assess changes like body temperature, especially increase in body temperature: Fever is associated with the systemic manifestation of inflammation and thus may point out the presence of infection.
- Evaluate the patient’s level of distress: Pain is part of the typical inflammatory process. However, the extent and depth of injury may affect pain sensations.
- Assess the characteristics of the wound including size, color, drainage, and odor: The findings will give information on the extent of the impaired tissue integrity or injury. A pale tissue color is an indication of decreased oxygenation, while odor may signal the presence of infection on the injured tissue. The odor may also come from necrotic tissue. Serous exudate from injured tissue is a common part of inflammation and must be differentiated from pus or purulent discharge that is present in the infection.
- Know the signs of itching and scratching: The patient who scratches their skin in an attempt to alleviate severe itching may open skin injury and heighten the risk for infection.
- Categorize pressure ulcers by assessing the extent of tissue damage: Wound evaluation is more reliable if categorized in a manner recommended by the National Pressure Ulcer Advisory Panel. These are the stages of pressure ulcers:
- Stage I: Non-blanchable erythema signals potential ulceration.
- Stage II: Partial-thickness skin loss e.g abrasion, shallow crater, or blister involving the epidermis may extend through to the dermis.
- Stage III: Full-thickness tissue loss entailing damage to or necrosis of the subcutaneous tissue may extend down but not extending through the underlying fascia. The ulcer appears as a deep crater that might undermine the adjacent tissue.
- Stage IV: Full-thickness tissue loss with severe destruction, tissue necrosis, or damage to muscle, bone, or supporting structures such as tendons, joint capsules
- Pay attention to all the high-risk tissues like bony prominences, skin folds, heels, and sacrum: A systemic inspection and assessment in these areas can enable identifying of impending problems early for the provision of prompt treatment.
- Determine a plan for debridement when necrotic tissue e.g slough or eschar is present or if compatible with general patient management goals: Often, healing does not transpire in the appearance of necrotic tissue.
- Evaluate the patient’s nutritional status, recommend for nutritional consultation, and institute supplements: Insufficient nutritional intake puts the patient at risk for tissue breakdown while compromising the healing process, thereby causing impaired tissue integrity.
- Assess the site of impaired tissue integrity and its status: The swelling, redness, pain, itching, and burning are all indications of inflammation and the body’s immune system response to localized tissue trauma or impaired tissue integrity.
Nursing Interventions for Impaired Tissue Integrity
A nurse care plan for impaired tissue skin integrity is never complete without therapeutic interventions to assist in the healing process. A nurse should intervene in the following ways:
- Monitor the area of impaired tissue integrity preferably daily, for color changes, swelling, pain, redness, and other signs of infection: This systematic inspection can identify imminent problems early.
- Educate the patient on the need to notify the physician or nurse: Notifying the nurse or caregiver will prevent further impaired tissue integrity complications.
- Encourage the use of pillows, foam wedges, and other pressure-reducing devices: By doing this, you will prevent pressure injury.
- Teach tissue and wound assessment and ways to assess and monitor for signs and symptoms of complications, infection, and healing: Timely assessment and intervention help prevent aggravation of the problems.
- Educate the patient, significant other, and family in the proper care of the wound including wound cleansing, hand washing, dressing changes, and application of topical medications: Giving this information accurately increases the patient’s ability to manage therapy independently to reduce the risk for infection.
- Do not position the patient in areas of impaired tissue integrity. If necessary, turn and position the patient at least every 2 hours, and carefully transfer the patient: By doing this, you avoid the adverse effects of external mechanical forces such as pressure friction and shear.
- Check every 2 hours for proper placement of footboards, traction, restraints, casts, or other devices and evaluate the skin and tissue integrity: Mechanical injury to the skin and tissues by pressure, shear, or friction, is often linked to external devices.
- For patients with limited mobility, utilize the risk assessment tool to systematically evaluate immobility-related risk factors: By doing so, you can identify patients at the risk for immobility-related skin breakdown.
- Maintain the head of the bed at the lowest level of elevation as possible: This position will significant reduce friction and shear.
- Deliberate relationship between adequate nutrition consisting of protein, fluids, vitamin B and C, iron, and calories: Without a doubt, nutrition plays an essential role in maintaining tissue and skin intake while promoting wound healing.
- Monitor for proper placement of tubes, catheters, and other devices. Evaluating skin and tissue affected by the tape that secures these devices: Mechanical damage to skin and tissue as a result of friction, shear, and pressure is commonly associated with external devices.
- Encourage a diet that meets nutritional needs: A high-protein, high-calorie diet is essential in promoting the healing of the damaged tissue or skin.
- Tell the patient to avoid rubbing and scratching. Provide gloves or clip the nails when necessary: Scratching and rubbing can cause more injury, damage, and delay the healing process.
- Monitor the status of the tissue or skin around the wound. Monitor the patient’s skincare practices while keeping in mind the type of soap or cleaning agents used, the temperature of the water, and frequency of skin cleansing: Personalized impaired tissue integrity is necessary according to the patient’s skin condition, preference, and needs.
- Provide tissue care as needed: Every type of impaired tissue integrity is best treated based on its etiology. Since wounds can be covered with dry or wet dressings, topical creams or lubricants, hydrocolloid dressings, or vapor-permeable membrane dressings like Tegaderm, the dress replaces the protective function of the damaged tissue or skin during the healing process.
- Wet thoroughly the dressings with sterile normal saline solution before removal: Saturating dressings is aimed at easing the removal by loosening adherents to decrease pain for the patient, especially if tissue damage is caused by burns.
- Pre-medicate for dressing changes as needed: Manipulation of profound or extensive cuts, damage, or injuries can be painful.
- Maintain a sterile dressing technique during wound care: A sterile dressing technique reduces the risk of infection in impaired tissue integrity.
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