NURSING DIAGNOSIS: Risk for impaired tissue integrity

related to:
  1. accumulation of waste products and decreased oxygen and nutrient supply to the skin and subcutaneous tissue associated with reduced blood flow resulting from prolonged pressure on the tissues;
  2. damage to the skin and/or subcutaneous tissue associated with friction or shearing;
  3. increased fragility of the skin associated with dependent edema 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. Determine client's risk for skin breakdown using a risk assessment tool (e.g. Knoll Assessment Tool, Braden Scale, Gosnell Scale).
  2. Inspect the skin, especially bony prominences and dependent areas, for pallor, redness, and breakdown.
  3. Implement measures to prevent tissue breakdown:
    1. assist client to turn at least every 2 hours unless contraindicated
    2. position client properly; use pressure-reducing or pressure-relieving devices (e.g. pillows, gel or foam cushions, alternating pressure mattress, air-fluidized bed, kinetic bed) if indicated
    3. gently massage around reddened areas at least every 2 hours
    4. apply a thin layer of a dry lubricant such as powder or cornstarch to bottom sheet or skin and to opposing skin surfaces (e.g. axillae, beneath breasts) if indicated to reduce friction
    5. lift and move client carefully using a turn sheet and adequate assistance
    6. perform actions to keep client from sliding down in bed (e.g. gatch knees slightly when head of bed is elevated 30º or higher) in order to reduce the risk of skin surface abrasion and shearing
    7. instruct or assist client to shift weight at least every 30 minutes
    8. keep client's skin clean
    9. thoroughly dry skin after bathing and as often as needed, paying special attention to skin folds and opposing skin surfaces (e.g. axillae, perineum, beneath breasts); pat skin dry rather than rub
    10. keep bed linens dry and wrinkle-free
    11. ensure that external devices such as braces, casts, and restraints are applied properly
    12. protect the skin from contact with urine and feces (e.g. keep perineal area clean and dry, apply a protective ointment or cream to perineal area)
    13. perform actions to prevent drying of the skin:
      1. encourage a fluid intake of 2500 ml/day unless contraindicated
      2. provide a mild soap for bathing
      3. apply moisturizing lotion and/or emollient to skin at least once a day
    14. apply a protective covering such as a hydrocolloid or transparent membrane dressing to areas of the skin susceptible to breakdown (e.g. coccyx, heels, elbows)
    15. perform actions to maintain an adequate nutritional status (see Diagnosis 3, action c)
    16. if edema is present:
      1. perform actions to reduce fluid accumulation in dependent areas:
        1. instruct client in and assist with range of motion exercises
        2. elevate affected extremities whenever possible
      2. handle edematous areas carefully
    17. increase activity as allowed.
  4. If tissue breakdown occurs:
    1. notify appropriate health care provider (e.g. physician, wound care specialist)
    2. perform care of involved areas as ordered or per standard hospital procedure.