NURSING DIAGNOSIS: Risk for impaired tissue integrity
damage to the skin and/or subcutaneous tissue associated with prolonged pressure on the tissues, friction, and/or shearing if mobility is decreased;
increased fragility of the skin associated with edema, poor tissue perfusion, and inadequate nutritional status.
The client will maintain tissue integrity as evidenced by:
absence of redness and irritation
no skin breakdown.
Nursing Actions and
Inspect the skin, especially bony prominences and dependent and edematous areas, for pallor, redness, and breakdown.
Refer to Care Plan on Immobility, Diagnosis 4, actions c and d, for measures to prevent and treat tissue breakdown associated with decreased mobility.
Implement additional measures
to prevent tissue breakdown:
to improve tissue perfusion and reduce edema:
implement measures to increase cardiac output (see Diagnosis 1, action b)
implement measures to restore fluid balance (see Diagnosis 3, action D)
perform actions to maintain an adequate nutritional status (see Diagnosis 4, action c).