Assessment of the skin should include such subjective data as reported itching or pain and a history Impaired tissue integrity exposure to solar or other radiation or to an allergen, infectious agent, or parasite, or to extreme heat or cold.
Radiated skin becomes thin and friable, may have less blood supply, and is at higher risk for breakdown. Assess general condition of skin.
If skin is redden or swollen, then the area must be massaged every 2 hours to help stimulate blood flow. All bed sheets and other linen must be wrinkle free and dry.
If skin integrity is compromised, the healthcare provider — i. Wound assessment is more reliable when performed by the same caregiver, the client is in Impaired tissue integrity same position, and the same techniques are used Krasner, Sibbald, ; Sussman, Bates-Jensen, Identify a plan for debridement if necrotic tissue eschar or slough is present and if consistent with overall client management goals.
These areas include the heels, coccyx and elbows. Some hospitals may have the information displayed in digital format, or use pre-made templates.
Common causes of friction include the patient rubbing heels or elbows against bed linen and moving the patient up in bed without the use of a lift sheet. What nursing care plan book do you recommend helping you develop a nursing care plan? If there is edema in the dependent areas of the body the client should be 1 assisted with some type of motion exercise and 2 the extremity should be elevated, whenever possible.
For clients with limited mobility, Impaired tissue integrity a risk assessment tool to systematically assess immobility-related risk factors.
Caution should always be taken to not dry out the wound Panel for the Prediction and Prevention of Pressure Ulcers in Adults, ; Bergtrom et al, ; Ovington, Care Plans are often developed in different formats. Immobility is the greatest risk factor in skin breakdown.
Contractures are note in both upper extremities. Teach skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing. The skin is subject to injury from a variety of external and internal factors. Pain in the area.
Determine size and depth of wound e. Each type of wound is best treated based on its etiology. Patient reports any altered sensation or pain at site of tissue impairment.
Instruct patient, significant others, and family in proper care of the wound including hand washingwound cleansing, dressing changes, and application of topical medications. Internal factors include emaciation, drugs, altered circulation and impaired oxygen transport, altered metabolic state, and infections.
Encourage use of pillows, foam wedges, and pressure-reducing devices. Saturating dreesings will ease the removal by loosening adherents and decreasing pain, especially with burns.
Some ethicists feel that integrity is the first or primary virtue. Contractures are noted in both upper extremities. A written treatment plan ensures consistency in care and documentation Maklebust, Sieggreen, Use braces, casts or a wheelchair. A high-protein, high-calorie diet may be needed to promote healing.
Monitor for signs of infection like pain, fever, foul discharge, redness or pus collection. Measures to prevent skin breakdown 1. Do not position patient on site of impaired tissue integrity.
Fever is a systemic manifestation of inflammation and may indicate the presence of infection. Do not treat a patient based on this care plan. What are nursing care plans? A turn-sheet is ideal for moving patient as it prevents friction.
If patient is mentally alert and compliant, he or she should be asked to shift weight every minutes.Date & Sign. Plan and Outcome [Check those that apply] Target Date: Nursing Interventions [Check those that apply] Date Achieved: The patient will: (_)Maintain. Impaired tissue integrity related to inflammatory process damaging skin and underlying tissue, secondary to cellulitis, manifested by pain, redness, swelling, warmth of site, and fever LTG: Client will have no complications from cellulitis or hospital stay by discharge.5/5(4).
Risk for Impaired Skin Integrity: Vulnerable to alteration in epidermis and/or dermis, which may compromise health.
Start studying Tissue Integrity. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Impaired Skin Integrity related to malnutrition and pressure ulcers as evidence by disruption of epidermal and dermal tissues.
Subjective Data: Unable to walk for. Jul 22, · 1. Assess site of impaired tissue integrity and determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, leg ulcer).
Prior assessment of wound etiology is critical for proper identification of nursing interventions (van Rijswijk, ). 2.Download