NURSING DIAGNOSIS: Risk for impaired tissue integrity

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