ASSESSMENT NURSING DIAGNOSIS CLIENT GOAL OUTCOME CRITERIA NURSING INTERVENTIONS RATIONALE ACTUAL EVALUATION

SUBJECTIVE CUES: Impaired Skin Integrity After 4-6 hours of SHORT TERM INDEPENDENT SHORT TERM:
“I have this laceration related to mechanical nursing 1. Monitored site of impaired tissue 1. Systematic inspection can
on my scalp because trauma secondary to interventions, the After 4-6 hours of nursing integrity at least once daily for color identify impending problems early. At the end of the shift, the
I fell from the tree scalp laceration. client will be able interventions, the client will changes, redness, swelling, client was able to:
while I was playing” to demonstrate be able to: warmth, pain, or other signs of
SCIENTIFIC BASIS: and display infection. 1. Have reduced risk of further
Impaired skin integrity improved wound 2. Individualize plan is necessary
1. Have reduced risk of impairment of skin integrity.
OBJECTIVE CUES: is a nursing diagnosis healing. 2. Monitored status of skin around according to patient’s skin
further impairment of skin
 presence of scalp accepted by the North wound. Monitor patient’s skin care condition, needs, and preferences.
integrity. 2. Describe measures to
laceration on the American Nursing practices, noting the type of soap or
left parietal area Diagnosis other cleansing agents used, protect and heal the skin and
 with chief Association, defined 2. Describe measures to temperature of water, and to care for any skin lesion
complaints of as alteration in the protect and heal the skin frequency of skin cleansing.
scalp laceration epidermis and/or and to care for any skin 3. That may contribute to skin 3. Report any altered
and swollen left dermis. The skin is lesion 3. Assessed for environmental maceration. sensation or pain at site of skin
forearm subject to injury from moisture (wound drainage, high impairment.
3. Report any altered
 with localized a variety of external sensation or pain at site of humidity).
erythema on and internal factors skin impairment. 4. This is to avoid the adverse 4. Demonstrate understanding
surrounding area such as mechanical 4. Restrained the patient from effects of external mechanical of plan to heal skin and
of laceration trauma, scratches. 4. Demonstrate positioning on site of impaired forces (pressure, friction, and prevent reinjury
 with reports of skin tear or understanding of plan to tissue integrity. If ordered, turned shear).
itchiness of area lacerations, and heal skin and prevent and positioned patient at least LONG TERM:
surrounding surgical incision. reinjury every 2 hours, and carefully
lacerated portion transfer patient. 5. Each type of wound is best After 3-5 days of nursing
of scalp REFERENCE: treated based on its etiology. Skin interventions, the client will be
 with doctor’s Impaired skin integrity. LONG TERM 5. Provided tissue care as needed. wounds may be covered with wet or able to:
order to perform (n.d.) Miller-Keane After 3-5 days of nursing dry dressings, topical creams or
wound dressing Encyclopedia and interventions, the client was lubricants, hydrocolloid dressings or 1. Demonstrate lifestyle
change on scalp Dictionary of able to: vapor-permeable membrane changes to avoid progression
laceration Medicine, Nursing, dressings such as Tegaderm. The of skin impairment.
 Vital signs taken and Allied Health, dressing replaces the protective
1. Demonstrate lifestyle
as follows: Seventh Edition. function of the injured tissue during 2. Maintain appropriate
changes to avoid
T- 36.7C (2003). the healing process. measures that can be taken to
progression of skin
P- 90bpm treat or prevent impaired skin
impairment.
R- 24cpm integrity.
BP- 90/60mmhg
2. Maintain appropriate 6. This technique reduces the risk
measures that can be taken of infection in impaired tissue 3. Regain skin integrity and
to treat or prevent impaired 6. Maintained an aseptic/sterile integrity. timely wound healing.
skin integrity. dressing technique during wound
care. 4. Be free from signs of wound
3. Regain skin integrity and 7. Saturating dressings will ease infection.
timely wound healing. 7. Wet thoroughly the dressings the removal by loosening adherents
with sterile normal saline solution and decreasing pain, especially
4. Be free from signs of before removal. with burns.
wound infection. 8. Monitored patient’s continence 8. This is to prevent exposure to
status and minimize exposure of chemicals in urine and stool that
skin impairment site and other can strip or erode the skin causing
areas to moisture from further impaired tissue integrity.
incontinence, perspiration, or
wound drainage.
9. Rubbing and scratching can
9. Instructed patient to avoid cause further injury and delay
rubbing and scratching. Provide healing.
gloves or clip the nails if necessary.
10. Educating patients and
10. Educated patient and family caregivers methods to maintain
members/caregivers about proper skin integrity enhances their sense
nutrition, hydration, and methods to of self-efficacy and prevents skin
maintain tissue integrity. breakdown.

1. Wounds may be managed well

DEPENDENT and more efficiently with topical
1. Administered antibiotics as agents, although intravenous
ordered. antibiotics may be indicated.

COLLABORATIVE 1. Patients receiving collaborative

1. Collaborated with other health wound care showed more
care professionals for individualized improvement in wound healing and
wound care that can be continued management. This also promotes
by the patient after discharge. active, rather than passive, role and
enhances self-control.

2. Adequate nutrition consisting of

2. Collaborated with dietician in fluids, protein, vitamins B and C,
selecting food choices that promote iron, may be needed to promote
wound healing. healing.

Source:
Nurseslabs. 2021. Impaired Tissue
(Skin) Integrity – Nursing Diagnosis
& Care Plan. [online] Available at:
<https://nurseslabs.com/impaired-
 tissue-integrity/>

REFERENCES:

Doenges, ME., Moorhouse, MF., & Murr, A.C. (2016). Nurse’s Pocket Guide. F. A. Davis Company.
Gulanick, M, & Myers, J. L. (2016) Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier Health Sciences.
Impaired skin integrity. (n.d.) Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. (2003).
Nursinginterventionsrationales.com. 2021. Impaired Skin integrity. [online] Available at: <http://nursinginterventionsrationales.com/2013/07/impaired-skin-integrity.html>
Nurseslabs. 2021. Impaired Tissue (Skin) Integrity – Nursing Diagnosis & Care Plan. [online] Available at: <https://nurseslabs.com/impaired-tissue-integrity/>