Impaired Tissue integrity

Minggu, 28 Juli 2013

Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues

Defining Characteristics: Damaged or destroyed tissue (e.g., cornea, mucous membrane, integumentary, or subcutaneous)

Related Factors:

  • Mechanical (e.g., pressure, shear, friction); 
  • radiation (including therapeutic radiation); 
  • nutritional deficit or excess; 
  • thermal (temperature extremes); 
  • knowledge deficit;
  • irritants, chemical (including body excretions, secretions, medications); 
  • impaired physical mobility; 
  • altered circulation; 
  • fluid deficit or excess

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Tissue Integrity: Skin and Mucous Membranes
  • Wound Healing: Primary Intention
  • Wound Healing: Secondary Intention
Client Outcomes
  • Reports any altered sensation or pain at site of tissue impairment
  • Demonstrates understanding of plan to heal tissue and prevent injury
  • Describes measures to protect and heal the tissue, including wound care
  • Wound decreases in size and has increased granulation tissue

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Incision Site Care
  • Pressure Ulcer Care
  • Skin Care: Topical Treatments
  • Skin Surveillance
  • Wound Care

Nursing Interventions and Rationales

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, 2001).

2. Determine size and depth of wound (e.g., full-thickness wound, stage III or stage IV pressure ulcer). Wound assessment is more reliable when performed by the same caregiver, the client is in the same position, and the same techniques are used (Krasner, Sibbald, 1999; Sussman, Bates-Jensen, 1998).

3. Classify pressure ulcers in the following manner:
  • 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 (National Pressure Ulcer Advisory Panel, 1989).
  • Stage IV: Full-thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures (e.g., tendons, joint capsules) (National Pressure Ulcer Advisory Panel, 1989).
4. Monitor site of impaired tissue integrity at least once daily for color changes, redness, swelling, warmth, pain, or other signs of infection. Determine whether client is experiencing changes in sensation or pain. Pay special attention to all high-risk areas such as bony prominences, skin folds, sacrum, and heels.
Systematic inspection can identify impending problems early (Bryant, 1999).

5. Monitor status of skin around wound. Monitor client's skin care practices, noting type of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing.
Individualize plan according to client's skin condition, needs, and preferences. Avoid harsh cleansing agents, hot water, extreme friction or force, or cleansing too frequently (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992; Bergstrom, 1994).

6. Monitor client's continence status and minimize exposure of skin impairment site and other areas to moisture from incontinence, perspiration, or wound drainage.

7. If client is incontinent, implement an incontinence management plan to prevent exposure to chemicals in urine and stool that can strip or erode the skin. Refer to a physician (e.g., urologist, gastroenterologist) for an incontinence assessment (Doughty, 2000; Wound, Ostomy, and Continence Nurses Society, 1992, 1994).

8. Monitor for correct placement of tubes, catheters, and other devices. Assess skin and tissue affected by the tape that secures these devices (Faller, Beitz, 2001).
Mechanical damage to skin and tissues as a result of pressure, friction, or shear is often associated with external devices.

9. In orthopedic clients, check every 2 hours for correct placement of foot boards, restraints, traction, casts, or other devices, and assess skin and tissue integrity. Be alert for symptoms of compartment syndrome (see care plan for Risk for Peripheral neurovascular dysfunction).
Mechanical damage to skin and tissues (pressure, friction, or shear) is often associated with external devices.

10. For clients with limited mobility, use a risk assessment tool to systematically assess immobility-related risk factors.
A validated risk assessment tool such as the Norton or Braden scale should be used to identify clients at risk for immobility-related skin breakdown (Bergstrom et al, 1987; Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992; Krasner, Sibbald, 1999).

11. Implement a written treatment plan for topical treatment of the skin impairment site.
A written treatment plan ensures consistency in care and documentation (Maklebust, Sieggreen, 1996). Topical treatments must be matched to the client, wound, and setting (Krasner, Sibbald, 1999; Ovington, 1998).

12. Identify a plan for debridement if necrotic tissue (eschar or slough) is present and if consistent with overall client management goals.
Healing does not occur in the presence of necrotic tissue (Panel for the Prediction and Prevention of Pressure ulcers in Adults, 1992; Bergstrom et al, 1994; Krasner, Sibbald, 1999).

13. Select a topical treatment that maintains a moist wound-healing environment that is balanced with the need to absorb exudate and fill dead space.
Caution should always be taken to not dry out the wound (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992; Bergtrom et al, 1994; Ovington, 1998).

14. Do not position client on site of impaired tissue integrity. If consistent with overall client management goals, turn and position client at least every 2 hours, and carefully transfer client to avoid adverse effects of external mechanical forces (pressure, friction, and shear).
Evaluate for use of specialty mattresses, beds, or devices as appropriate (Fleck, 2001). If the goal of care is to keep the client (e.g., a terminally ill client) comfortable, turning and repositioning may not be appropriate. Maintain the head of the bed at the lowest degree of elevation possible to reduce shear and friction, and use lift devices, pillows, foam wedges, and pressure-reducing devices in the bed (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992; Krasner, Rodeheaver, Sibbald, 2001).

15. Avoid massaging around site of impaired tissue integrity and over bony prominences.
Research suggests that massage may lead to deep-tissue trauma (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).

16. Assess client's nutritional status; refer for a nutritional consultation and/or institute dietary supplements.
Inadequate nutritional intake places the client at risk for skin breakdown and compromises healing (Demling, De Santi, 1998).

Home Care Interventions

1. Instruct and assist client and caregivers with removing or controlling impediments to wound healing (e.g., management of underlying disease, improvement in approach to client positioning, improved nutrition).
Wound healing can be delayed or fail totally if impediments are not controlled (Krasner, Sibbald, 1999).

2. Initiate a consultation in a case assignment with a wound, ostomy, continence nurse (WOC nurse) to establish a comprehensive plan as soon as possible.

Client/Family Teaching

1. Teach skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing.
Early assessment and intervention helps prevent the development of serious problems (van Rijswijk, 2001).

2. Teach use of a topical treatment that is matched to client, wound, and setting.
The topical treatment needs to be adjusted as the status of the wound changes (Krasner, Sibbald, 1999).

3. If consistent with overall client management goals, teach how to turn and reposition client at least every 2 hours.
If the goal of care is to keep the client (e.g., a terminally ill client) comfortable, turning and repositioning may not be appropriate (Krasner, Rodeheaver, Sibbald, 2001; Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).

4. Teach use of pillows, foam wedges, and pressure-reducing devices to prevent pressure injury.

12 komentar:

Anonim mengatakan...

Your composing is purely awe-inspiring that I desired to read such high quality material... CNA Practice Test

Unknown mengatakan...

I have a brother who recently sustained some pretty serious wounds and tissue damage in a car accident. Luckily it looks like he's going to be okay. I'm just hoping that he can make a full recovery from all the damage. Hopefully he can find a good wound care treatment. I think he'll need a lot of help! http://www.skilledwoundcare.com/nursing-homes/

Unknown mengatakan...

This is a good reasearch write up. Imapired tissue integrity is a wide a vast part in nursing terminology. It takes a bit of a time to do a research like this. I just want to thank you for this.
diploma of nursing

Leona Knight mengatakan...

I was diagnosed of Herpes 2 years ago and I have tried all possible means to get the cure but all to no avail, until I saw a post in a health forum about a Herbal Doctor(Dr Akhigbe) who prepares herbal medicine to cure all kind of diseases including Herpes, at first i doubted, if it was real but decided to give him a trial, when I contacted Dr Akhigbe through his Email: drrealakhigbe@gmail.com he guided me and prepared a herbal medicine and sent it to me via courier Delivery service,when I received the package (herbal medicine) He gave me instructions on how to consume it,I started using it as instructed and I stopped getting outbreaks and the sores started vanishing, could you believe I was cured of this deadly virus within two to three weeks and notices changes in my body. Days of using this REMEDY,couldn't believe the healing at first until I see it as my HERPES get cleared like magic Dr Akhigbe also use his herbal medicine to cure diseases like, HIV, HERPES, CANCER, ALS, CHRONIC DISEASE, HEART DISEASE, LUPUS, ASTHMA, DIABETES HEPATITIS A AND B.ECZEMA, BACK PAIN, EXTERNAL EFFECTION ION,EPILEPSY,STROKE,KIDNEY DISEASE,ACME. etc Contact this great herbal Doctor today the father of herbal root cure. via Email: drrealakhigbe@gmail.com or whatsapp him +2348142454860 and get cured permanently He is real..

website: https:drrealakhigbe.weebly.com

Noah Roland mengatakan...

Hello everyone! my name is Noah, I'm writing this article to appreciate the good work of DR AKHIGBE that helped me recently to bring back my wife that left me for another man for the past 6 months. After seeing a comment of a woman on the internet testifying of how she was helped by DR AKHIGBE I also decided to contact him for help because all i wanted was for me to get my wife, happiness and to make sure that my child grows up with his mother 'I love my wife' Am happy today that he helped me and i can proudly say that my wife is now with me again and she is now in love with me like never before. Are you in need of any help in your relationship like getting back your man, wife, boyfriend, girlfriend or loves and family relationship. Viewers reading my post that needs the help of DR AKHIGBE should contact him via E-mail: drrealakhigbe@gmail.com You can also call or contact him via whatsapp +2348142454860 He also cure deadly diseases and virus with his natural herbal medicine herbs. like
HIV/AIDS
HERPES
EPILEPSY
STROKE
EXTERNAL INFECTION
CANCER
DIABETES
CHRONIC DISEASE
HEPATITIS A&B AND OTHERS. his email again: drrealakhigbe@gmail.com
number : +2348142454860

Unknown mengatakan...

My name is hoover, my 18 years old daughter, Tricia was diagnosed of herpes 3 years ago. ever since then,we have been going from one hospital to the other. We tried all sorts of pills but all efforts to get rid of the virus was futile. The blisters kept on reappearing after some months. My daughter was making use of Acyclovir tablets 200mg. 2 tablets every 6hours and fusitin cream 15grams. and H5 POT. Permanganate with water to be applied 2x a day but all still show no result. So I was on the internet some months back, to sought for any other means of saving my only child. just then, i came across a comment on dr imoloa herbal treatment and decided to give it a try. i contacted the him and he prepared some herbs and sent it to me together with guidelines on how to use the herbs through DHL courier service. my daughter used it as directed dr imoloa and in less than 14days, my daughter regained her health.. You should contact Dr imoloa today directly on his email address for any kind of health challenge; lupus disease,  mouth ulcer,  mouth cancer, body pain, fever, hepatitis A.B.C.,   syphilis,  diarrhea,  HIV/AIDS,  Huntington's Disease,   back acne,  Chronic renal failure,   addison disease,  Chronic Pain,   Crohn's Disease,   Cystic Fibrosis,  Fibromyalgia,   Inflammatory Bowel Disease,  fungal nail disease, Lyme Disease, Celia disease, Lymphoma, Major Depression,  Malignant Melanoma,   Mania,  Melorheostosis,   Meniere's Disease,  Mucopolysaccharidosis , Multiple Sclerosis,  Muscular Dystrophy,  Rheumatoid Arthritis, Alzheimer's Disease, parkison disease, vaginal cancer, epilepsy,  Anxiety Disorders, Autoimmune Disease,   Back Pain,  Back Sprain,   Bipolar Disorder,  Brain Tumour,  Malignant,   Bruxism, Bulimia,  Cervical Disk Disease, cardiovascular disease, Neoplasms, chronic respiratory disease,  mental and behavioural disorder,     Cystic Fibrosis,   Hypertension, Diabetes, asthma,  Inflammatory autoimmune-mediated arthritis.  chronic kidney disease, inflammatory joint disease,  impotence,  feta alcohol spectrum,  Dysthymic Disorder,   Eczema, tuberculosis,  Chronic Fatigue Syndrome, constipation, inflammatory bowel disease.  and many more; contact him on email- drimolaherbalmademedicine@gmail.com./ also on  whatssap-+2347081986098.

Becky Lynch mengatakan...

I Never believed i was ever going to be HSV FREE again, DR.Ehiaguna has given me reasons to be happy, i was HSV positive for 2 years and all the means and medicine i tried for treatment was not helpful to me, but when i came on the Internet i saw great testimony about DR.Ehiaguna on how he was able to cure someone from HSV 2, this person said great things about this man, and advice we contact him for any Disease problem that DR.Ehiaguna can be of help, well i decided to give him a try, he requested for my information which i sent to him, and he told me he was going to prepare for me a healing portion, which he wanted me to take for days, and after which i should go back to the hospital for check up, well after taking all the treatment sent to me by DR.Ehiahuna , i went back to the Hospital for check up, and now i have been confirmed HSV NEGATIVE, friends you can reach DR.Ehiaguna on any treatment of any Disease cos i saw many testimony of different disease like, HEPATITIS,HIV AIDS,EPILEPSY, CANCER,CFS he is the one only one i can show you all up to, reach him on drehiaguna@gmail.com or whatsApp him now +2348073908953. quick contact him for help and you can just quickly drop your number on your first mail as i did for easily conversation

Nanda mengatakan...

Impaired Tissue Perfusion r/t Encephalitis

Tommy mengatakan...

I am amazed by Ohikhobo's remedy. I Have had herpes for over 6 years with frequent outbreaks. Sometimes I average 2-3 times per month. Before one breakout could end, the next would begin. Nothing has helped me. I came online in search for a possible way to see how I can fight this virus so I found Ohikhobo here online after seeing a lot of testimonies of how he cured herpes and other diseases with natural herbs so I decided to give it a try I only took his remedy for two weeks and I was completely cured. I recommend Ohikhobo's remedy to anyone suffering from herpes that wants to be completely cured too.

Email: drohikhoboherbalcenter @ gmail com

WhatsApp +1740-231-2427

Tom Neil mengatakan...

Hi, there. I am Tom Neil and I need to describe how life had been for my younger brother living with schizophrenia and how he had been permanently able to subdue this debilitating disease via a naturopathic, herbal procedure.

Maicon - my kid brother was twenty years old when he was brought to the emergency room by the campus police of the college from which he had been suspended several months ago. A professor had called and reported that he had walked into his classroom, accused him of taking his tuition money, and refused to leave.

Although he had much academic success as a teenager, his behavior had become increasingly odd during the past year. He quit seeing his friends and no longer seemed to care about his appearance or social pursuits. He began wearing the same clothes each day and seldom bathed. He lived with several family members but rarely spoke to any of them. When he did talk to them, he said he had found clues that his college was just a front for an organized crime operation. He had been suspended from college because of missing many classes. My sister said that she had often seen him mumbling quietly to himself and at times he seemed to be talking to people who were not there. He would emerge from my room and ask my family to be quiet even when they were not making any noise.

My father and sister told the staff that Maicon's great-grandmother had had a serious illness and had lived for 30 years in a state hospital, which they believed was a mental hospital. Our mother left the family when Maicon was very young. She has been out of touch with us, and they thought she might have been treated for mental health problems.

Maicon agreed to sign himself into the psychiatric unit for treatment. The whole family except I had agreed to have Maicon transferred to a mental asylum. I knew inwardly there was still some plausible means by which my kid brother could overcome this condition. I knew botanical means of treatment will be more favorable than any other type of treatment, and as such, I had taken a keen interest in the research of naturopathic alternative measures suitable for the treatment of schizophrenia. I had pleaded for some little patience from the family in the delay of the transfer, I was looking forward to proving a point to the entire family, of a positive botanical remedy for this condition.

It was during my ceaseless search on the internet I had been fortunate enough to come across Dr. Utu Herbal Cure: an African herbalist and witch doctor whose professional works had majored on the eradication of certain viral conditions, especially schizophrenia, ( improving the memory capacity positively), via a traditional, naturopathic process and distinguished diet plan. It was by the administration of this herbal specialist that my brother had been able to improve his condition for better.

Before the naturopathic remedy - Maicon's story had reflected a common case, in which a high-functioning young adult goes through a major decline in day-to-day skills. Although family and friends may feel this is a loss of the person they knew, the illness can be treated and a good outcome is possible.

My brother Maicon is just like many other patients out there suffering from this disease. Although he was able to overcome this condition via a naturopathic herbal remedy administered by this African herbal physician and saved completely thus, rekindling the lost joy which had been experienced by the family members.

I wish to use this opportunity to reach across to anyone who may happen to be diagnosed with this disastrous condition to spread the hope of an everlasting herbal remedy that is capable of imposing a permanent end to this disease.

For more information concerning this naturopathic herbal remedy, feel free to contact this African herbal practitioner via email:
drutuherbalcure@gmail.com

Ali jan mengatakan...

What will probably astound you is that everybody can enjoy the benefits of massage therapy. 남양주출장안마

buy fioricet online

Posting Komentar