Identify three (3) nursing interventions to protect skin integrity for an immobile client. ati

You can use this guide to help you develop your nursing care plan and nursing interventions for impaired tissue integrity. 

What constitutes our body’s protection against external threats? Yes, it’s the integumentary system. Specifically, our skin, cornea, subcutaneous tissues, and mucous membranes are our first line of defense against threats from the external environment. In a normal setting, these defenses are adequate to defend the body from any threats. However, some factors may cause impairment or a break in this line of defense, causing impairment of tissue integrity.

The most common cause includes physical trauma (e.g., car accidents, sports injuries, cuts, blunt trauma, etc.). Other causes can be related to thermal factors (e.g., burns, frostbites), or chemical injury (e.g., adverse reactions to drugs), infection, nutritional imbalances, fluid imbalances, and altered circulation (e.g., pressure ulcers).

A break in tissue integrity is usually repaired by the body very well. However, there are circumstances that it doesn’t repair it at all and replaces the damaged tissue with connective tissue. When tissue integrity is left untreated, it could cause local or systemic infection and ultimately lead to necrosis.

See Also: Risk for Impaired Skin Integrity Care Plan » 

Other factors include age, weight loss, poor nutrition and hydration, excessive moisture and dryness, smoking, and other conditions affecting blood flow.

Signs and Symptoms

Impaired skin integrity is characterized by the following signs and symptoms:

• Affected area hot, tender to touch
• Damaged or destroyed tissue (e.g., cornea, mucous membranes, integumentary, subcutaneous)
• Local pain
• Protectiveness toward site
• Skin and tissue color changes (red, purplish, black)
• Swelling around the initial injury

Goals and Outcomes

The following are the common goals and expected outcomes for impaired tissue integrity. Use them in writing your short term or long term goals for your impaired tissue integrity care plan:

• Patient reports any altered sensation or pain at site of tissue impairment.
• Patient demonstrates understanding of plan to heal tissue and prevent injury.
• Patient describes measures to protect and heal the tissue, including wound care.
• Patient’s wound decreases in size and has increased granulation tissue.

Nursing Assessment and Rationales for Impaired Tissue Integrity

Assessment is required to recognize possible problems that may have lead to Impaired Tissue Integrity and identify any episode that may transpire during nursing care.

1. Determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, leg ulcer).
Prior assessment of wound etiology is critical for the proper identification of nursing interventions.

2. Assess the site of impaired tissue integrity and its condition.
Redness, swelling, pain, burning, and itching are indications of inflammation and the body’s immune system response to localized tissue trauma or impaired tissue integrity.

3. Assess characteristics of the wound, including color, size (length, width, depth), drainage, and odor.
These findings will give information on the extent of the impaired tissue integrity or injury. Pale tissue color is a sign of decreased oxygenation. An odor may result from the presence of infection on the site; it may also be coming from necrotic tissue. Serous exudate from a wound is a normal part of inflammation and must be differentiated from pus or purulent discharge present in the infection.

4. Assess changes in body temperature, specifically increased body temperature.
Fever is a systemic manifestation of inflammation and may indicate the presence of infection.

5. Assess the patient’s level of pain.
Pain is part of the normal inflammatory process. The extent and depth of injury may affect pain sensations.

6. Monitor site of impaired tissue integrity at least once daily for color changes, redness, swelling, warmth, pain, or other signs of infection.
Systematic inspection can identify impending problems early.

7. Monitor the status of the skin around the wound. Monitor patient’s skincare practices, noting the type of soap or other cleansing agents used, the temperature of the water, and frequency of skin cleansing.
Individualize plan is necessary according to the patient’s skin condition, needs, and preferences.

8. Know signs of itching and scratching.
The patient who scratches the skin to alleviate extreme itching may open skin lesions and increase the risk for infection.

9. Assess patient’s nutritional status; refer for a nutritional consultation or institute dietary supplements.
Inadequate nutritional intake places the patient at risk for skin breakdown and compromises healing, causing impaired tissue integrity.

10. Classify pressure ulcers by assessing the extent of tissue damage.
According to the National Pressure Ulcer Advisory Panel, wound assessment is more reliable when classified in such a manner. The following are the stages of pressure ulcers:

• Stage I. Nonblanchable erythema signaling potential ulceration.
• Stage II. Partial-thickness skin loss (abrasion, blister, or a shallow crater) involving the epidermis and may extend through the dermis.
• Stage III. full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia; ulcer appears as a deep crater with or without undermining of adjacent tissue.
• Stage IV. Full-thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures (e.g., tendons, joint capsules)

11. Monitor for proper placement of tubes, catheters, and other devices. Assess skin and tissue affected by the tape that secures these devices.
Mechanical damage to skin and tissues due to pressure, friction, or shear is often associated with external devices.

Nursing Interventions and Rationales for Impaired Tissue Integrity

The following are the therapeutic nursing interventions for Impaired Tissue Integrity nursing diagnosis:

1. Provide tissue care as needed.
Each type of wound is best treated based on its etiology. Skin wounds may be covered with wet or dry dressings, topical creams or lubricants, hydrocolloid dressings (e.g., DuoDerm), or vapor-permeable membrane dressings such as Tegaderm. An eye patch or hard plastic shield for corneal injury. The dressing replaces the protective function of the injured tissue during the healing process.

2. Keep a sterile dressing technique during wound care.
A sterile technique reduces the risk of infection in impaired tissue integrity. This involves the use of a sterile procedure field, sterile gloves, sterile supplies and dressing, sterile instruments (Kent et al., 2018).

3. Premedicate for dressing changes as necessary.
Manipulation of deep or extensive cuts or injuries may be painful.

4. Wet the dressings thoroughly with sterile normal saline solution before removal.
Saturating dressings will ease the removal by loosening adherents and decreasing pain, especially with burns.

5. Monitor patient’s continence status and minimize exposure of skin impairment site and other areas to moisture from incontinence, perspiration, or wound drainage.
Prevents exposure to chemicals in urine and stool that can strip or erode the skin causing further impaired tissue integrity.

6. If the patient is incontinent, implement an incontinence management plan.
Prevent exposure to chemicals in urine and stool that can strip or erode the skin.

7. Check every two (2) hours for proper placement of footboards, restraints, traction, casts, or other devices, and assess skin and tissue integrity.
Mechanical damage to skin and tissues (pressure, friction, or shear) is often associated with external devices.

8. Pay special attention to all high-risk areas such as bony prominences, skin folds, sacrum, and heels.
Systematic inspection can identify impending problems early and provide early treatment.

9. Identify a plan for debridement when necrotic tissue (eschar or slough) is present and if compatible with overall patient management goals
Healing does not transpire in the appearance of necrotic tissue.

10. Encourage the use of pillows, foam wedges, and pressure-reducing devices.
To prevent pressure injury.

11. Administer antibiotics as ordered.
Although intravenous antibiotics may be indicated, wound infections may be managed well and more efficiently with topical agents.

12. Tell the patient to avoid rubbing and scratching. Provide gloves or clip the nails if necessary.
Rubbing and scratching can cause further injury and delay healing.

13. Encourage a diet that meets nutritional needs.
A high-protein, high-calorie diet may be needed to promote healing.

14. Discuss the relationship between adequate nutrition consisting of fluids, protein, vitamins B and C, iron, and calories.
Nutrition plays a vital role in maintaining intact skin and in promoting wound healing.

15. For patients with limited mobility, use a risk assessment tool to assess immobility-related risk factors systematically.
Identifies the patient’s risk for immobility-related skin breakdown.

16. Do not position the patient on the site of impaired tissue integrity. If ordered, turn and position the patient at least every two (2) hours and carefully transfer the patient.
This is to avoid the adverse effects of external mechanical forces (pressure, friction, and shear).

17. Maintain the head of the bed at the lowest degree of elevation possible.
To reduce shear and friction.

18. Educate patient about proper nutrition, hydration, and methods to maintain tissue integrity.
The patient needs proper knowledge of their condition to prevent impaired tissue integrity.

19. Teach skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing.
Early assessment and intervention help prevent the development of serious problems.

20. Instruct patient, significant others, and family in the proper care of the wound, including handwashing, wound cleansing, dressing changes, and application of topical medications).
Accurate information increases the patient’s ability to manage therapy independently and reduces the risk for infection.

21. Educate the patient on the need to notify the physician or nurse.
This is to prevent further impaired tissue integrity complications.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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• Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
  An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
• Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
  A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
• NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
  The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
• Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
  Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
  Useful for creating nursing care plans related to mental health and psychiatric nursing.
• Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
  Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
• Maternal Newborn Nursing Care Plans (3rd Edition)
  If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
• Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
  An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
• All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
  Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.

See also

Other recommended site resources for this nursing care plan:

References and Sources

Recommended resources for the nursing diagnosis impaired tissue integrity and care plan:

1. Baranoski, S., & Ayello, E. A. (2008). Wound care essentials: Practice principles. Lippincott Williams & Wilkins.
2. Berman, A., Snyder, S. J., Kozier, B., Erb, G. L., Levett-Jones, T., Dwyer, T., … & Parker, B. (2014). Kozier & Erb’s Fundamentals of Nursing Australian Edition (Vol. 3). Pearson Higher Education AU.
3. Carpenito-Moyet, L. J. (2006). Handbook of nursing diagnosis. Lippincott Williams & Wilkins.
4. Corbett, L. Q. (2012). Wound care nursing: professional issues and opportunities. Advances in wound care, 1(5), 189-193.
5. Hardy, M. A. (1990). A pilot study of the diagnosis and treatment of impaired skin integrity: dry skin in older persons. International Journal of Nursing Terminologies and Classifications, 1(2), 57-63.
6. Iverson-Carpenter, M. S. (1988). Impaired skin integrity. Journal of geron
7. Kent, D. J., Scardillo, J. N., Dale, B., & Pike, C. (2018). Does the use of clean or sterile dressing technique affect the incidence of wound infection?. Journal of Wound, Ostomy and Continence Nursing, 45(3), 265-269.
8. Malaquias, S. G., Bachion, M. M., Martins, M. A., Nunes, C. A. D. B., Torres, G. D. V., & Pereira, L. V. (2014). Impaired tissue integrity, related factors and defining characteristics in persons with vascular ulcers. Texto & Contexto-Enfermagem, 23(2), 434-442.
9. Menna Barreto, L. N., Swanson, E. A., & de Abreu Almeida, M. (2016). Nursing outcomes for the diagnosis impaired tissue integrity (00044) in adults with pressure ulcer. International journal of nursing knowledge, 27(2), 104-110.
10. Menna Barreto, L. N., Silva, M. B. D., Engelman, B., Figueiredo, M. S., Rodríguez‐Acelas, A. L., Cañon‐Montañez, W., & Almeida, M. D. A. (2019). Evaluation of surgical wound healing in orthopedic patients with impaired tissue integrity according to nursing outcomes classification. International journal of nursing knowledge, 30(4), 228-233.
11. Mendham, J. E. (2004). Gabapentin for the treatment of itching produced by burns and wound healing in children: a pilot study. Burns, 30(8), 851-853.
12. Murphy, J. V., Banwell, P. E., Roberts, A. H., & McGrouther, D. A. (2000). Frostbite: pathogenesis and treatment. Journal of Trauma and Acute Care Surgery, 48(1), 171.
13. Pezzi, M. V., Rabelo‐Silva, E. R., Paganin, A., & de Souza, E. N. (2016). Nursing Interventions and Outcomes for the Diagnosis of Impaired Tissue Integrity in Patients After Cardiac Catheterization: Survey. International journal of nursing knowledge, 27(4), 215-219.
14. Ratliff, C. (1990). Impaired skin integrity related to radiation therapy. Journal of enterostomal therapy, 17(5), 193.
15. Piloian, B. B. (1992). Defining characteristics of the nursing diagnosis” high risk for impaired skin integrity”. Decubitus, 5(5), 32-4.