The most common cause of pressure wounds and skin integrity issues is constant pressure to the skin as it gets squeezed against a surface such as a bed or wheelchair.
Skin and tissue color changes red, purplish, black Swelling around initial injury The following are the common goals and expected outcomes for Impaired Tissue Integrity.
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. Nursing Assessment Assessment is required in order to recognize possible problems that may have lead to Impaired Tissue Integrity as well as identify any episode that may transpire during nursing care.
Assessment Determine etiology e. Prior assessment of wound etiology is critical for proper identification of nursing interventions. Assess site of impaired tissue integrity and its condition. Assess characteristics of wound, including color, size length, width, depthdrainage, and odor.
These findings will give information on extent of injury. Pale tissue color is a sign of decreased oxygenation. Odor may be a result of presence of infection on the site; it may also be coming from a necrotic tissue. Serous exudate from a wound is a normal part of inflammation and must be differentiated from pus or purulent discharge, which is present in infection.
Assess changes in body temperature, specifically increased in body temperature. Fever is a systemic manifestation of inflammation and may indicate the presence of infection.
Pain is part of the normal inflammatory process. The extent and depth of injury may affect pain sensations. Know signs of itching and scratching. The patient who scratches the skin in attempts to alleviate extreme itching may open skin lesion and increase risk for infection.
Inadequate nutritional intake places the patient at risk for skin breakdown and compromises healing. Classify pressure ulcers in the following manner: Wound assessment is more reliable when classified in such manner according to the National Pressure Ulcer Advisory Panel.
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 musclebone, or supporting structures e.
Systematic inspection can identify impending problems early. Identify a plan for debridement if 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. Nursing Interventions The following are the therapeutic nursing interventions for Impaired Tissue Integrity: Interventions Rationales Monitor site of impaired tissue integrity at least once daily for color changes, redness, swelling, warmth, pain, or other signs of infection.
Monitor status of skin around wound. 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. An eye patch or hard, plastic shield for corneal injury.
The dressing replaces the protective function of the injured tissue during the healing process. Keep a sterile dressing technique during wound care. This technique reduces the risk for infection. Premedicate for dressing changes as necessary.
Manipulation of profound or extensive cuts or injuries may be painful. Wet thoroughly the dressings with sterile normal saline solution before removal. Saturating dreesings will ease the removal by loosening adherents and decreasing pain, especially with burns. This is to prevent exposure to chemicals in urine and stool that can strip or erode the skin.
If patient is incontinent, implement an incontinence management plan. Administer antibiotics as ordered. Wound infections may be managed well and more efficiently with topical agents, although intravenous antibiotics may be indicated.Mormon women blogging about the peculiar and the treasured.
Impaired skin integrity related to scrubbing the back of arms as evidence by rough and dry skin on the posterior side of upper arms.
L.C.R. has bumps on the back of her arms. She admits to” using a luffa to the back of her arms to keeping the pores open.”. A look at zinc deficiency, a condition where the body doesn’t have enough of the mineral. Included are details on causes and how it is diagnosed. Pressure Ulcers-Impaired Skin Integrity Order DescriptionIt is assignment for Planning Care for the Adult (The focus of the assignment should relate to the assessment and care planning of a patient with specific nursing management/clinical needs.
Reflecting on your previous clinical experience, you will demonstrate awareness and appraise the . Nursing Care Plan (Impaired Skin Integrity) - Free download as Word Doc .doc), PDF File .pdf), Text File .txt) or read online for free.
a nursing care plan i developed for a patient with pediculosis.5/5(96). EDITOR'S NOTE. Behind the lens again, photographer Hudson shoots the team that got the Gulf War babies' story told: left to right, reporter Briggs; senior editor Robert Sullivan, and contributing editor Kenneth Miller, who wrote the piece.