Nursing Diagnosis: Impaired Tissue Integrity r/t unintentional trauma.
NANDA Definition: Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues.
Cause Analysis: “The intact skin is an extremely efficient physical barrier to harmful agents and environmental forces, such as heat, cold, and
trauma. This protection is afforded by the keratinized surface cells, which provide a tough, dense, waterproof covering. Beneath this outmost
layer is a dense layer highly vascularized connective tissue. The creation of a wound disrupts the integrity of skin and its protective function.”-
(Long, Phipps, & Cassmeyer, (1993). A Nrsg. Process Approach Medical-Surgical Nursing, p.318). & (Smeltzer & Bare, (2000). Textbook of
Medical-Surgical Nursing, p.362).
Assessment NIC with Interventions Rationale with Reference Outcomes
Subjective: NIC 1: Wound Care NOC: Tissue Integrity
1. Complaints of pain in
lacerated wounds. Assessment Patient and family members
2. Protective action toward Determine the etiology of tissue Information guides design of communicates understanding
site. damage. optimal treatment plan. of skin care regimen.
(Gulanick/Myers. (2007). NCP Condition of impaired tissue
Objective: th
6 edition. 196.) improves as evidenced by
1. Sutured lacerated wound Inspect patient’s skin every shift. To ensure early treatment. dryness, no redness, and not
3cm anterior aspect @ Report areas of breakdown and (Sparks and swelling wounds
right leg. signs of infection. Taylor’[Link]
2. Sutured lacerated wound
8cm anteromedial aspect Diagnosis Reference Manual 7th
right leg edition. Lippincott Williams
3. Sutured lacerated wound and Wilkins. p.190)
4cm left knee Assess the patient’s level of Depth of wound may affect
4. Sutured lacerated wound discomfort. pain sensations.
7cm anteromedial aspect (Gulanick/Myers. (2007). NCP
Left knee
6th edition. 197.)
5. Pink dry stoma, left
Comfort Measures
anterior axillary line
Cleanse with normal saline or a This removes debris and
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nontoxic cleanser, as appropriate. pathogens. (Gulanick/Myers.
(2007). NCP 6th edition. 197.)
Provide skin care as needed. For Each type of wound is best
example, cover wound with wet treated based on its etiology.
or dry dressing, using topical (Gulanick/Myers. (2007). NCP
creams or lubricants. 6th edition. 197.)
Teachings Teaching increases the patient’s
Instruct patient or caregiver ability to manage therapy
in proper care of wound. independently.
(Gulanick/Myers. (2007). NCP
6th edition. 197.)
NIC 2: Infection Control
Assessment Classifying the surgical wounds
Classify the surgical wound facilitates the assessment of the
according to the degree of risk of wound infection and
contamination of the wound and subsequent tissue injury.
surrounding tissue. (Sparks and
Taylor’[Link]
Diagnosis Reference Manual 7th
edition. Lippincott Williams
and Wilkins. p.384)
Redness, swelling, pain,
Assess condition of tissue. burning and itching are signs of
the body’s immune response to
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localized tissue trauma.
(Gulanick/Myers. (2007). NCP
6th edition. 196.)
Fever can be an indication of
Assess for elevated body infection unless the patient is
temperature. immunocompromised.
(Gulanick/Myers. (2007). NCP
6th edition. 196.)
The patient who scratches the
Identify signs of itching and skin in attempts to relieve
scratching. intense itching may open skin
lesions and increase risk for
infection. (Gulanick/Myers.
(2007). NCP 6th edition. 197.)
Comfort Measures Rubbing and scratching can
Discourage rubbing and cause further injury and delay
scratching. Provide gloves healing. (Gulanick/Myers.
or clip nails if necessary. (2007). NCP 6th edition. 197.)
This reduces risk for infection.
Maintain sterile dressing (Gulanick/Myers. (2007). NCP
changes as needed. 6th edition. 197.)
Teachings
Instructed the client and To prevent
family members on the infection(Ignatavicius.
importance of proper (2006).Med-Surg.354)
handwashing
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Taught the patient and
caregiver to report the following Early assessment prompts early
signs indicating wound infection: intervention.(Gulanick.
purulent drainage, odor, fever, (2007).NCP 6th ED.1111)
malaise.
NIC 3: Nutrition and Hydration
Assess nutritional status.
Patients who are seriously
nutritionally depleted are at
risk for developing infection
and are unable to heal. .
(Gulanick.(2007).NCP 6th
Instruct patient to have a ED.1101)
diet high in protein, A diet that is high in protein,
calories, and vitamin C calories, and vitamin C
promotes wound healing.
(Ignatavicius.(2006).Med-
Collaborative Measures Surg.355)
Gentamycin 80 mg IVTT
q 80 Destroys gram-negative
bacteria by irreversibly
binding to 30S subunit of
bacterial ribosomes and
blocking protein synthesis,
resulting in misreading of
genetic code and separation of
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Cefixime 1 gm IVTT q 80 ribosomes from messenger.
ANST Inhibits bacterial cell wall
synthesis, rendering cell wall
osmotically unstable, leading
Tazocin/Piptaz 4.5 mg to cell death.
IVTT Piperacillin Inhibits bacterial
cell wall synthesis, resulting in
cell death. Tazobacatm
increases piperacillin efficacy.
Care Plan Evaluation:
The formulated care plan is effective because it is realistically applied to the client and the client’s SO as evidenced by communication about skin
care regimen and wound appearance of the client is dry, no redness and not swelling.
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