The skin, our body’s largest organ, serves as a vital protective barrier against the external environment. This remarkable system prevents pathogens from invading and causing illness. However, when this barrier is compromised due to various insults such as cuts, abrasions, ulcers, surgical incisions, or wounds, it becomes vulnerable, allowing bacteria and other harmful agents to penetrate, potentially leading to infections and further complications. For nurses, a deep understanding of assessing, preventing, managing, and educating patients about impaired tissue integrity is paramount in providing holistic and effective patient care.
This article delves into the multifaceted nature of impaired tissue integrity, providing a comprehensive guide for nurses and healthcare professionals. We will explore the underlying causes, presenting signs and symptoms, expected patient outcomes, thorough nursing assessments, evidence-based interventions, and practical nursing care plans. Our aim is to equip you with the knowledge and tools necessary to excel in promoting tissue integrity and preventing complications in your patients.
Unveiling the Causes of Impaired Tissue Integrity
Impaired tissue integrity, a state where the protective function of tissues is compromised, can stem from a wide array of factors. These factors can be broadly categorized into internal and external influences, each playing a significant role in tissue health and vulnerability.
Internal Factors Contributing to Impaired Tissue Integrity:
- Extremes of Age: Both very young and elderly individuals exhibit increased susceptibility to impaired tissue integrity. Neonates and infants have delicate, underdeveloped skin, while older adults often experience age-related skin changes such as thinning, decreased elasticity, and reduced moisture, making them more prone to injury and slower healing.
- Cognitive Impairment: Patients with cognitive deficits may be unable to understand or communicate their needs related to skin care, or they may be unaware of pressure or injury. This lack of awareness and self-care ability significantly increases their risk of developing pressure ulcers and other forms of tissue damage.
- Paralysis: Immobility due to paralysis, whether paraplegia or quadriplegia, drastically reduces a patient’s ability to reposition themselves and relieve pressure on bony prominences. Prolonged pressure leads to decreased blood flow and subsequent tissue ischemia and necrosis, resulting in pressure injuries.
- Physical Immobilization/Bedrest: Similar to paralysis, prolonged bedrest or physical immobilization for any reason restricts movement and increases pressure on dependent body areas. This is particularly concerning in post-surgical patients, those with acute illnesses, or individuals with mobility-limiting conditions.
- Hypothermia: Exposure to cold temperatures can cause vasoconstriction, reducing blood flow to the tissues. This decreased perfusion can lead to tissue ischemia and increase vulnerability to damage, especially in extremities.
- Hyperthermia: Conversely, elevated body temperature can increase metabolic demand and perspiration. Excessive sweating, if not properly managed, can lead to skin maceration and breakdown, particularly in skin folds and areas under pressure.
- Underlying Health Conditions: Certain chronic diseases significantly impact tissue integrity.
- Diabetes Mellitus: Diabetes is associated with impaired microcirculation, neuropathy (nerve damage leading to reduced sensation), and compromised immune function. These factors collectively increase the risk of skin infections, delayed wound healing, and diabetic ulcers, particularly in the feet and lower legs.
- Peripheral Vascular Disease (PVD): PVD restricts blood flow to the extremities, leading to chronic tissue ischemia. This makes tissues more fragile, susceptible to injury, and slow to heal, often resulting in arterial ulcers and increased risk of infection.
- Malnutrition: Inadequate intake of essential nutrients, particularly protein, vitamins (especially Vitamin C and Zinc), and minerals, impairs the body’s ability to repair and regenerate tissues. Malnourished individuals are at higher risk of pressure ulcers, poor wound healing, and infections.
- Obesity: Obesity can create skin folds that trap moisture and friction, increasing the risk of intertrigo (skin fold dermatitis) and fungal infections. Adipose tissue is also less vascularized, which can impair wound healing.
- Immunodeficiency: Conditions or treatments that suppress the immune system (e.g., HIV/AIDS, chemotherapy, immunosuppressant drugs) increase susceptibility to infections, which can further compromise tissue integrity and complicate wound healing.
External Factors Contributing to Impaired Tissue Integrity:
- Moisture/Secretions: Prolonged exposure to moisture, whether from perspiration, incontinence (urine or stool), wound drainage, or other bodily secretions, can lead to skin maceration. Macerated skin becomes softened, weakened, and more vulnerable to breakdown from friction and pressure.
- Chemicals: Exposure to harsh chemicals, irritants, and allergens can directly damage the skin, causing contact dermatitis, burns, and tissue breakdown. This includes strong cleaning agents, solvents, certain medications, and even some skincare products.
- Radiation: Radiation therapy, used in cancer treatment, can cause radiation dermatitis, a skin reaction ranging from mild redness and dryness to severe blistering and ulceration. Radiation damages skin cells and underlying tissues, impairing their integrity and healing capacity.
- Shearing Forces: Shearing occurs when skin and underlying tissues move in opposite directions, such as when a patient slides down in bed. These forces cause damage to blood vessels and tissues, contributing to pressure ulcer development.
- Friction: Friction, the force of rubbing skin against a surface, can erode the epidermis, making the skin more susceptible to breakdown, particularly in areas of repeated movement or pressure, like heels and elbows.
- Pressure: Prolonged, unrelieved pressure, especially over bony prominences (sacrum, heels, hips, elbows), is a primary cause of pressure ulcers. Pressure restricts blood flow, leading to tissue ischemia, necrosis, and ulceration.
- Surgical Incisions: While necessary for many medical procedures, surgical incisions disrupt skin integrity and create a portal of entry for pathogens. Improper wound care or surgical site infections can further impair tissue integrity and delay healing.
- Wounds: Traumatic wounds, burns, ulcers, and other skin lesions directly represent impaired tissue integrity. The type, depth, and location of the wound will influence the extent of tissue damage and the healing process.
Recognizing the Signs and Symptoms of Impaired Tissue Integrity
Identifying impaired tissue integrity early is crucial for timely intervention and prevention of further complications. Nurses must be vigilant in assessing patients for both subjective and objective signs and symptoms.
Subjective Symptoms (Patient Reports):
- Pain: Pain, ranging from mild discomfort to severe agony, is a common complaint associated with impaired tissue integrity. The type and intensity of pain can vary depending on the cause and extent of tissue damage.
- Itching (Pruritus): Itching can be a symptom of skin irritation, dryness, or allergic reactions. While not always indicative of impaired tissue integrity alone, persistent itching, especially if accompanied by other skin changes, warrants further assessment.
- Numbness or Tingling: Patients may report numbness, tingling, or altered sensation in the affected area or surrounding skin. This can be a sign of nerve damage or impaired circulation contributing to tissue compromise.
Objective Signs (Nurse Assesses):
- Changes in Skin Color:
- Erythema (Redness): Redness is a common sign of inflammation, increased blood flow, and early tissue damage. Persistent erythema, especially over bony prominences, should be carefully evaluated for potential pressure ulcer development.
- Bruising (Ecchymosis): Bruising indicates trauma and blood vessel damage. It can be a sign of injury or shearing forces contributing to tissue impairment.
- Blanching: Normal skin blanches (turns pale) when pressure is applied and returns to its normal color when pressure is released, indicating adequate capillary refill. Non-blanching erythema, where the skin remains red even when pressure is applied, is a critical sign of pressure ulcer development, indicating tissue damage due to impaired blood flow.
- Pallor (Paleness): Paleness can indicate reduced blood flow to the tissues, potentially due to vasoconstriction or circulatory issues, increasing the risk of tissue ischemia.
- Cyanosis (Bluish Discoloration): Cyanosis, a bluish tint to the skin, signifies severe oxygen deprivation and tissue hypoxia, a critical sign requiring immediate intervention.
- Changes in Skin Temperature:
- Warmth to Skin: Increased warmth around an area of impaired tissue integrity can indicate inflammation or infection.
- Coolness to Skin: Coolness, especially in extremities, may suggest impaired circulation and reduced blood flow, increasing the risk of tissue damage due to ischemia.
- Swelling (Edema): Swelling of tissues surrounding an area of impaired skin integrity can be a sign of inflammation, fluid accumulation, or compromised lymphatic drainage.
- Observed Open Areas or Breakdown: This is the most direct and evident sign of impaired tissue integrity. It includes:
- Abrasions: Superficial injuries involving the epidermis.
- Lacerations: Cuts or tears in the skin.
- Ulcers: Deeper lesions extending into the dermis and potentially subcutaneous tissue, muscle, or bone. Pressure ulcers, venous ulcers, arterial ulcers, and diabetic ulcers are common types.
- Excoriation: Skin breakdown caused by scratching or rubbing, often due to itching or irritation.
- Blisters: Fluid-filled pockets on the skin, often caused by friction, burns, or certain skin conditions.
- Fissures: Cracks in the skin, often due to dryness or fungal infections.
- Drainage: Any fluid leaking from an area of impaired tissue integrity should be assessed for color, odor, consistency, and amount. Purulent drainage (pus) is a clear sign of infection.
- Odor: Foul odor emanating from a wound or skin lesion is a strong indicator of infection.
Expected Outcomes: Goals for Tissue Integrity
Establishing clear and measurable goals is essential in nursing care planning for patients with impaired tissue integrity. These outcomes guide interventions and provide a framework for evaluating the effectiveness of care. Common goals and expected outcomes include:
- Patient will maintain intact tissue integrity: This overarching goal aims to prevent further skin breakdown and promote the health of existing intact skin.
- Patient will experience timely healing of wounds without complications: For patients with existing wounds, the goal is to facilitate efficient wound closure and minimize the risk of infection, delayed healing, or other complications.
- Patient will demonstrate effective wound care: This outcome emphasizes patient education and self-management. Patients or their caregivers should be able to perform prescribed wound care procedures correctly and confidently.
- Patient will verbalize proper prevention strategies: Education is key to long-term tissue integrity maintenance. Patients should understand risk factors and preventive measures to avoid future skin breakdown, particularly pressure injuries.
- Patient will report any changes in skin condition promptly: Empowering patients to be active participants in their care includes educating them to recognize and report any new signs or symptoms of impaired tissue integrity, allowing for early intervention.
- Patient will demonstrate improved comfort and reduced pain related to impaired tissue integrity: Pain management is an integral part of care. Expected outcomes include pain reduction and improved patient comfort.
Comprehensive Nursing Assessment for Impaired Tissue Integrity
A thorough nursing assessment is the cornerstone of effective care for patients at risk for or experiencing impaired tissue integrity. This involves systematic data collection, encompassing both subjective and objective information, to identify risk factors, existing problems, and guide appropriate interventions.
1. Conduct a Comprehensive Skin Assessment:
A head-to-toe skin examination should be performed upon admission, during unit transfers, and at least once per shift, and more frequently as needed based on patient risk and condition. This routine assessment is critical for early detection and prevention of skin breakdown. Pay particular attention to high-risk areas, including bony prominences such as:
- Sacrum and Coccyx (Tailbone)
- Heels
- Hips
- Elbows
- Shoulder blades
- Back of the head (occiput)
- Knees
- Ankles
- Ischial tuberosities (sitting bones)
- Trochanters (hip bones)
Assess the skin for:
- Color: Note any redness, pallor, cyanosis, jaundice, or abnormal pigmentation.
- Temperature: Palpate the skin to assess for warmth, coolness, or temperature variations.
- Moisture: Evaluate for dryness, excessive sweating (diaphoresis), or maceration.
- Turgor: Gently pinch the skin to assess hydration status and elasticity. Decreased turgor (skin that tents or stays pinched) can indicate dehydration and reduced skin resilience.
- Texture: Assess for smoothness, roughness, dryness, or presence of lesions, rashes, or masses.
- Integrity: Inspect for any breaks in the skin, wounds, ulcers, abrasions, lacerations, excoriation, blisters, fissures, or drainage.
2. Utilize the Braden Scale for Pressure Ulcer Risk Assessment:
The Braden Scale is an evidence-based tool widely used to assess a patient’s risk for developing pressure ulcers. It evaluates six key risk factors:
- Sensory Perception: Ability to respond meaningfully to pressure-related discomfort.
- Moisture: Degree to which skin is exposed to moisture.
- Activity: Degree of physical activity.
- Mobility: Ability to change and control body position.
- Nutrition: Usual food intake pattern.
- Friction and Shear: Assesses the amount of friction and shear forces the patient is exposed to.
Each category is scored on a scale, and the total score ranges from 6 to 23. Lower scores indicate higher risk. Institutional policy dictates the frequency of Braden Scale assessments, but nurses should also use it whenever they suspect a patient is at increased risk of skin breakdown.
Braden Scale Scoring Interpretation:
- 19-23: Very low risk
- 15-18: Low risk
- 13-14: Moderate risk
- 10-12: High risk
- ≤ 9: Very high risk
3. Assess Circulatory Status:
Evaluate the patient’s circulatory status, particularly in the extremities, as adequate blood flow is essential for tissue health and wound healing. Assess:
- Peripheral Pulses: Palpate pulses (dorsalis pedis, posterior tibial, popliteal, femoral, radial, brachial) to assess pulse strength and regularity. Diminished or absent pulses may indicate impaired arterial circulation.
- Capillary Refill: Press on a nailbed or skin area until it blanches, then release pressure and observe the time it takes for color to return. Normal capillary refill is less than 3 seconds. Delayed refill suggests impaired microcirculation.
- Skin Color and Temperature of Extremities: Note any pallor, cyanosis, or coolness in the extremities, which can indicate poor circulation.
- Presence of Edema: Assess for edema (swelling), particularly in the lower extremities. Edema can impair circulation and increase skin fragility.
4. Assess Activity Level and Mobility:
Observe the patient’s ability to move and reposition themselves independently. Consider:
- Ambulation: Can the patient walk independently, with assistance, or not at all?
- Bed Mobility: Can the patient turn, reposition, and lift themselves in bed?
- Chair Mobility: Can the patient transfer to and from a chair and reposition themselves while sitting?
- Use of Assistive Devices: Note any use of wheelchairs, walkers, canes, or other mobility aids.
- Restraints: Patients using physical restraints are at significantly increased risk of pressure ulcers due to restricted movement and potential friction/shear.
5. Determine Risk of Skin Breakdown Related to Moisture:
Assess the patient’s exposure to moisture and potential sources:
- Incontinence: Is the patient incontinent of urine or stool? Frequency and severity of incontinence should be documented.
- Perspiration (Diaphoresis): Is the patient experiencing excessive sweating due to fever, exertion, or medical conditions?
- Wound Drainage: Note the type, amount, and frequency of wound drainage.
- Other Secretions: Assess for other bodily fluids that may contribute to skin moisture, such as saliva, gastric drainage, or respiratory secretions.
6. Evaluate Patient’s Ability for Self-Care:
Assess the patient’s functional abilities and limitations related to skin care:
- Hygiene: Can the patient bathe, shower, and perform perineal care independently?
- Dressing: Can the patient dress and undress themselves, including managing clothing and shoes that may cause friction or pressure?
- Incontinence Management: Can the patient manage incontinence independently, including using the toilet, changing absorbent products, and maintaining perineal hygiene?
- Communication: Can the patient communicate their needs related to skin care, such as discomfort, itching, or wetness?
7. Describe and Document Any Existing Wounds:
Accurate and detailed documentation of wounds is crucial for tracking healing progress and evaluating treatment effectiveness. For each wound, document:
- Location: Precise anatomical location.
- Type: (e.g., pressure ulcer, surgical wound, laceration, burn, diabetic ulcer, venous ulcer, arterial ulcer).
- Stage (for Pressure Ulcers): Use a validated staging system (e.g., National Pressure Ulcer Advisory Panel stages I-IV, Unstageable, Deep Tissue Pressure Injury).
- Size: Measure length, width, and depth in centimeters.
- Wound Bed: Describe the tissue type (e.g., granulation, slough, eschar).
- Periwound Skin: Describe the skin surrounding the wound (e.g., erythema, edema, maceration, induration).
- Drainage: Describe color, odor, consistency, and amount.
- Odor: Note any presence and quality of odor.
- Tunneling or Undermining: Assess for and document any tracts or areas of tissue destruction extending beyond the visible wound edges.
- Pain: Assess and document pain level using a pain scale.
- Photographic Documentation: Consider taking photographs of the wound for baseline and progress tracking, following institutional policy and patient consent guidelines.
8. Assess Nutritional and Hydration Status:
Adequate nutrition and hydration are vital for tissue repair and wound healing. Assess:
- Dietary Intake: Review the patient’s usual dietary intake, including protein, calories, vitamins, and minerals. Identify any nutritional deficiencies or restrictions.
- Fluid Intake: Assess daily fluid intake and output. Dehydration can impair tissue perfusion and healing.
- Weight: Monitor weight changes, as unintentional weight loss can indicate malnutrition.
- Albumin and Prealbumin Levels: These serum protein levels are indicators of nutritional status and can be assessed through lab tests.
9. Assess Stoma and Ostomy Site (if applicable):
For patients with ostomies, assess the stoma and surrounding skin:
- Stoma Appearance: Assess for color (should be pink to red and moist), size, shape, and protrusion. Note any signs of ischemia (pale, dusky, or black), necrosis, or retraction.
- Peristomal Skin: Examine the skin around the stoma for irritation, redness, breakdown, or signs of infection.
- Ostomy Appliance Fit: Assess the fit and seal of the ostomy pouching system. Poorly fitting appliances can lead to skin irritation and leakage.
Nursing Interventions: Promoting Tissue Integrity and Wound Healing
Nursing interventions are crucial in preventing and treating impaired tissue integrity. These interventions are tailored to address the identified risk factors and specific needs of each patient.
1. Implement Prescribed Wound Care Protocols:
Follow established wound care protocols based on wound type, location, size, stage, and facility policies. Wound care protocols may include:
- Wound Cleansing: Gentle cleansing with appropriate solutions (e.g., normal saline) to remove debris and exudate. Avoid harsh antiseptics that can damage healthy tissue.
- Debridement: Removal of necrotic tissue (slough, eschar) to promote wound healing. Debridement methods may include sharp, enzymatic, mechanical, autolytic, or biologic debridement, depending on the wound and practitioner expertise.
- Dressing Selection: Choosing appropriate dressings based on wound type, drainage amount, and healing stage. Dressings should maintain a moist wound environment, protect the wound from trauma and contamination, and absorb excess exudate. Examples include:
- Gauze dressings: For absorption and protection.
- Transparent films: For superficial wounds and as secondary dressings.
- Hydrocolloids: For partial-thickness wounds with minimal to moderate drainage.
- Hydrogels: For dry wounds to provide moisture.
- Foam dressings: For wounds with moderate to heavy drainage.
- Alginates and fibers: For highly exudating wounds.
- Antimicrobial dressings: For infected wounds.
- Topical Medications: Application of prescribed topical agents, such as antimicrobial ointments, growth factors, or enzymatic debriding agents, as ordered.
- Wound Vac Therapy (Negative Pressure Wound Therapy): For complex or slow-healing wounds, wound vac therapy may be used to promote wound closure by applying negative pressure.
2. Position and Reposition Patients Frequently:
Regular repositioning is essential to relieve pressure on bony prominences and promote tissue perfusion.
- Turn Schedule: Establish a turning schedule, typically every 2 hours, or more frequently as needed, especially for high-risk patients. Use a turn clock or reminder system to ensure adherence to the schedule.
- Pressure Relief: Use pillows, wedges, foam cushions, or pressure-redistributing mattresses to offload bony prominences and distribute weight evenly.
- Positioning Aids: Utilize positioning devices to maintain proper body alignment and prevent pressure points.
- Chair Repositioning: For patients sitting in chairs, encourage repositioning every hour or more frequently. Ensure proper chair fit and consider pressure-relieving cushions.
- Avoidance of Prolonged Sitting or Lying in One Position: Educate patients and caregivers about the importance of frequent position changes.
3. Ensure Adequate Skin Perfusion:
Promote blood flow to tissues to prevent ischemia and support healing.
- Avoid Restrictive Clothing or Devices: Ensure clothing and medical devices (e.g., casts, braces) are not too tight and do not impede circulation.
- Promote Circulation: Encourage range-of-motion exercises, ambulation (if appropriate), and avoid prolonged periods of sitting with legs crossed.
- Maintain Hydration: Adequate fluid intake is essential for blood volume and tissue perfusion.
- Manage Underlying Conditions: Optimize management of conditions that impair circulation, such as diabetes and peripheral vascular disease.
4. Maintain Dry and Clean Skin:
Prevent skin maceration and irritation by keeping skin clean and dry.
- Gentle Cleansing: Cleanse skin regularly with mild, pH-balanced cleansers and warm water. Avoid harsh soaps, hot water, and excessive scrubbing.
- Pat Skin Dry: Pat skin dry gently after cleansing, especially in skin folds. Avoid rubbing, which can cause friction.
- Moisture Barriers: Apply moisture barrier creams or ointments to protect skin from excessive moisture, particularly in incontinent patients.
- Manage Incontinence Promptly: Implement bowel and bladder management programs to minimize skin exposure to urine and stool. Use absorbent products and change them frequently.
- Wick Moisture: Use absorbent pads or dressings to wick away perspiration or wound drainage.
5. Alleviate Pressure:
Reduce pressure on vulnerable areas using pressure-redistributing support surfaces and devices.
- Pressure-Redistributing Mattresses: Utilize low-air loss mattresses, alternating pressure mattresses, or foam mattresses to redistribute pressure and reduce pressure points.
- Support Surfaces: Use gel overlays, waffle boots, elbow protectors, and wedge pillows to offload specific bony prominences and provide support.
- Lift, Don’t Drag: When repositioning patients, lift them rather than dragging or sliding them across surfaces to minimize friction and shear.
- Heel Elevation: Elevate heels off the bed using pillows or heel suspension devices to prevent heel pressure ulcers.
6. Promote Proper Nutrition and Hydration:
Support tissue repair and wound healing with adequate nutrition and hydration.
- Nutritional Assessment and Support: Consult with a dietitian to assess nutritional status and develop an individualized nutrition plan. Ensure adequate protein, calories, vitamins (especially Vitamin C and Zinc), and minerals in the diet.
- Hydration Management: Encourage adequate fluid intake to maintain hydration and tissue perfusion. Monitor for signs of dehydration.
- Nutritional Supplements: Consider nutritional supplements, such as protein shakes or vitamin supplements, if dietary intake is insufficient.
7. Protect Skin from Further Injury:
Prevent additional trauma and injury to compromised skin.
- Protective Clothing: Encourage patients to wear loose-fitting, soft clothing to minimize friction. Advise diabetic patients to wear socks and protective shoes at all times to prevent foot injuries.
- Avoid Irritants: Minimize exposure to harsh chemicals, irritants, and allergens. Use gentle skincare products and avoid perfumes or fragranced lotions.
- Safe Transfers and Handling: Use proper body mechanics and assistive devices when transferring and repositioning patients to prevent friction and shear injuries.
- Padding and Protection: Pad splints, casts, and other medical devices to prevent pressure and friction against the skin.
8. Coordinate with Wound/Ostomy Specialists:
Consult with wound care and ostomy specialists for complex wounds, ostomy care, and specialized recommendations. These specialists can provide expert guidance on wound assessment, treatment, dressing selection, and ostomy management.
9. Avoid Irritation and Trauma to Stoma and Peristomal Skin:
For patients with ostomies, prevent irritation and breakdown of the stoma and surrounding skin.
- Proper Appliance Fit: Ensure the ostomy appliance (wafer and pouch) fits correctly and creates a secure seal around the stoma to prevent leakage and skin irritation.
- Barrier Pastes and Powders: Use barrier pastes and powders to protect peristomal skin from stomal output and adhesive irritation.
- Adhesive Removers: Use adhesive removers to gently remove ostomy appliances without stripping or damaging the skin.
- Regular Pouch Emptying: Empty ostomy pouches when they are 1/3 to 1/2 full to prevent them from pulling away from the skin due to weight.
- Patient Education on Ostomy Care: Educate patients and caregivers on proper ostomy care techniques, including appliance application, pouch emptying, skin care, and troubleshooting common problems.
10. Patient and Caregiver Education:
Empower patients and caregivers with knowledge and skills to prevent and manage impaired tissue integrity at home. Education should include:
- Risk Factors for Skin Breakdown: Identify individual risk factors and explain how they contribute to impaired tissue integrity.
- Preventive Measures: Teach strategies for preventing skin breakdown, including pressure relief, frequent repositioning, skin care, incontinence management, proper nutrition and hydration, and avoiding friction and shear.
- Wound Care Techniques: Provide clear instructions and demonstrations on prescribed wound care procedures, including cleansing, dressing changes, and medication application.
- Signs and Symptoms of Complications: Educate patients and caregivers to recognize signs of infection (increased redness, warmth, swelling, pain, purulent drainage, fever, odor) and other complications, and when to seek medical attention.
- Importance of Follow-Up Care: Emphasize the need for regular follow-up appointments with healthcare providers to monitor wound healing and tissue integrity.
Nursing Care Plans: Examples for Impaired Tissue Integrity
Nursing care plans provide a structured framework for organizing and delivering patient care. Here are examples of care plan components for patients with impaired tissue integrity, based on common underlying causes:
Care Plan Example 1: Impaired Skin Integrity related to Immobility
Diagnostic Statement: Impaired skin integrity related to immobility as evidenced by Stage 2 pressure ulcer on the sacrum.
Expected Outcomes:
- Patient will demonstrate improvement in pressure ulcer healing from Stage 2 to Stage 1 within 2 weeks of nursing interventions.
- Patient will maintain clean and dry skin at all times.
- Patient will verbalize understanding of pressure ulcer prevention strategies by discharge.
- Patient will participate in repositioning and mobility activities as tolerated.
- Patient will report any new areas of skin redness or breakdown promptly.
Assessment:
- Assess pressure ulcer characteristics (location, stage, size, wound bed, periwound skin, drainage, pain) at least daily.
- Assess patient’s mobility status and ability to reposition independently.
- Utilize Braden Scale daily to monitor pressure ulcer risk.
- Assess nutritional status and hydration.
- Assess patient’s understanding of pressure ulcer prevention and wound care.
Interventions:
- Perform wound care to sacral pressure ulcer as prescribed (e.g., cleansing, debridement, dressing changes).
- Reposition patient at least every 2 hours, using a written turning schedule.
- Utilize pressure-redistributing mattress and support surfaces.
- Keep skin clean and dry, especially in sacral area. Implement incontinence management strategies as needed.
- Provide adequate nutrition and hydration, consulting with dietitian as needed.
- Educate patient and caregiver on pressure ulcer prevention, proper positioning, skin care, and wound care.
- Encourage patient to participate in mobility and range-of-motion exercises within limitations.
Care Plan Example 2: Impaired Skin Integrity related to Diabetic Neuropathy
Diagnostic Statement: Impaired skin integrity related to decreased skin sensation secondary to diabetic neuropathy as evidenced by non-healing ulcer on the left foot.
Expected Outcomes:
- Patient will demonstrate signs of wound healing in foot ulcer within 4 weeks of nursing interventions.
- Patient will maintain blood glucose levels within target range.
- Patient will verbalize understanding of diabetic foot care and importance of daily foot inspections.
- Patient will demonstrate proper foot care practices, including daily inspection, cleansing, and moisturizing.
- Patient will wear appropriate footwear at all times.
Assessment:
- Assess foot ulcer characteristics (location, size, depth, wound bed, periwound skin, drainage, signs of infection) at least daily.
- Assess patient’s sensation in feet using monofilament testing or other neuropathy assessment tools.
- Monitor blood glucose levels regularly.
- Assess patient’s knowledge of diabetic foot care and self-management.
- Inspect patient’s footwear for proper fit and support.
Interventions:
- Perform wound care to foot ulcer as prescribed (e.g., offloading, cleansing, debridement, dressing changes, antimicrobial therapy if infected).
- Educate patient on importance of blood glucose control for wound healing and prevention of complications.
- Teach patient daily foot inspection techniques, emphasizing areas prone to injury.
- Instruct patient on proper foot hygiene, including gentle cleansing, thorough drying (especially between toes), and moisturizing with appropriate lotion.
- Advise patient to wear well-fitting, supportive shoes and avoid walking barefoot.
- Refer patient to podiatry for specialized foot care and footwear recommendations.
- Educate patient on signs and symptoms of foot infection and when to seek medical attention.
Care Plan Example 3: Impaired Skin Integrity related to Surgical Incision and Stoma Creation
Diagnostic Statement: Impaired skin integrity related to surgical incision and stoma creation to the abdomen.
Expected Outcomes:
- Patient will demonstrate proper care of surgical incision and peristomal skin by discharge.
- Patient will verbalize understanding of stoma care, appliance management, and peristomal skin protection.
- Patient will maintain a healthy, pink, and moist stoma.
- Patient will experience healing of surgical incision without signs of infection.
- Patient will report any signs of peristomal skin irritation or stoma complications promptly.
Assessment:
- Assess surgical incision site for signs of healing, infection (redness, warmth, drainage), and dehiscence or evisceration.
- Assess stoma characteristics (color, size, protrusion, moisture) and peristomal skin condition (irritation, redness, breakdown).
- Evaluate ostomy appliance fit and seal.
- Assess patient’s knowledge of surgical incision and stoma care.
- Monitor patient’s nutritional and hydration status.
Interventions:
- Provide incisional wound care as prescribed, including dressing changes and monitoring for infection.
- Collaborate with wound/ostomy specialist for stoma and peristomal skin care recommendations.
- Educate patient on proper ostomy appliance application, pouch emptying, peristomal skin care, and troubleshooting techniques.
- Instruct patient on signs and symptoms of peristomal skin irritation and stoma complications (e.g., prolapse, retraction, ischemia).
- Teach patient about dietary modifications to manage ostomy output and prevent diarrhea or constipation.
- Encourage adequate fluid intake and proper nutrition to promote healing and overall health.
- Provide emotional support and resources for coping with ostomy.
Care Plan Example 4: Impaired Skin Integrity related to Burn Wounds
Diagnostic Statement: Impaired skin integrity related to full-thickness burn wounds over 20% of total body surface area (TBSA).
Expected Outcomes:
- Patient will demonstrate evidence of wound healing and skin regeneration within expected timeframe.
- Patient will maintain a clean and infection-free wound environment.
- Patient will verbalize understanding of burn wound care and infection prevention measures.
- Patient will manage pain effectively during wound care and recovery.
- Patient will participate in rehabilitation and skin grafting procedures as needed.
Assessment:
- Assess burn wound characteristics (depth, extent, location, wound bed, drainage, signs of infection) daily.
- Assess patient’s pain level and response to pain management interventions.
- Monitor for signs and symptoms of burn wound infection (increased redness, warmth, swelling, purulent drainage, fever).
- Assess fluid and electrolyte balance and nutritional status.
- Evaluate patient’s psychosocial response to burn injury and coping mechanisms.
Interventions:
- Perform burn wound care as prescribed, including hydrotherapy, debridement, dressing changes (using aseptic technique), and application of topical antimicrobial agents.
- Administer pain medication as ordered and assess pain relief effectiveness.
- Maintain strict aseptic technique during all wound care procedures to prevent infection.
- Monitor vital signs and laboratory values for signs of infection and complications.
- Provide fluid and electrolyte replacement and nutritional support as needed.
- Provide emotional support and psychological counseling to patient and family.
- Coordinate with burn team specialists (surgeons, therapists, dietitians, psychologists) for comprehensive burn care.
- Educate patient and family on burn wound care, infection prevention, pain management, and rehabilitation plan.
Care Plan Example 5: Impaired Skin Integrity related to Radiation Therapy
Diagnostic Statement: Impaired skin integrity related to radiation therapy as evidenced by erythema and dry desquamation in the radiation treatment field.
Expected Outcomes:
- Patient will maintain skin integrity in radiation treatment field throughout radiation therapy.
- Patient will verbalize understanding of skin care measures to minimize radiation dermatitis.
- Patient will report any worsening skin reactions (blistering, open areas, drainage) promptly.
- Patient will manage discomfort related to radiation dermatitis effectively.
- Patient will avoid further skin irritation and sun exposure to the treated area.
Assessment:
- Assess skin integrity in radiation treatment field before each radiation therapy session and regularly throughout treatment.
- Assess patient’s understanding of radiation dermatitis and skin care measures.
- Evaluate patient’s pain and discomfort level related to skin reactions.
- Monitor for signs of skin breakdown, blistering, or infection in the treated area.
Interventions:
- Instruct patient to cleanse skin in radiation treatment field gently with mild soap and water, pat dry, and avoid harsh scrubbing.
- Advise patient to apply prescribed moisturizer to the treated area daily, avoiding application immediately before radiation therapy.
- Recommend loose-fitting, soft cotton clothing to minimize friction in the treated area.
- Educate patient to avoid sun exposure to the treated area and use sunscreen if sun exposure is unavoidable (after consulting with radiation oncology team).
- Advise patient to avoid using perfumes, lotions, deodorants, or powders in the radiation treatment field unless specifically recommended by the healthcare team.
- Provide pain relief measures as needed, such as topical analgesics or cool compresses.
- Instruct patient to report any worsening skin reactions (blistering, open areas, drainage, severe pain) to the healthcare team promptly.
These care plan examples provide a starting point for developing individualized care plans for patients with impaired tissue integrity. Nursing care plans should be tailored to each patient’s specific needs, risk factors, underlying conditions, and goals of care. Regular evaluation and revision of the care plan are essential to ensure ongoing effectiveness and optimal patient outcomes.
References
- Ackley, B. J., & Ladwig, G. B. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care. Elsevier.
- Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). Nursing diagnoses: Definitions and classification 2018-2020. Thieme.
- National Pressure Ulcer Advisory Panel (NPUAP). (2019). Prevention and treatment of pressure ulcers: Quick reference guide. Author.
- Registered Nurses’ Association of Ontario (RNAO). (2016). Risk assessment and prevention of pressure ulcers (4th ed.). RNAO.
- Wound, Ostomy and Continence Nurses Society (WOCN). (2017). Guideline for prevention and management of pressure ulcers (injuries). WOCN.
