CLINT S.
ANCOG
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.
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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.
