Nursing Interventions and Rationales For Impaired Tissue Integrity

CLINT S.
ANCOG
Nursing Interventions and Rationales

for Impaired Tissue Integrity
The following are the therapeutic nursing interventions for Impaired Tissue
Integrity nursing diagnosis:
1. Provide tissue care as needed.

Each type of wound is best treated based on its etiology. Skin wounds may be
covered with wet or dry dressings, topical creams or lubricants, hydrocolloid
dressings (e.g., DuoDerm), or vapor-permeable membrane dressings such as
Tegaderm. An eye patch or hard plastic shield for corneal injury. The dressing
replaces the protective function of the injured tissue during the healing process.
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2. Keep a sterile dressing technique during wound care.

A sterile technique reduces the risk of infection in impaired tissue integrity. This
involves the use of a sterile procedure field, sterile gloves, sterile supplies and
dressing, sterile instruments (Kent et al., 2018).
3. Premedicate for dressing changes as necessary.

Manipulation of deep or extensive cuts or injuries may be painful.
4. Wet the dressings thoroughly with sterile normal saline solution before

removal.
Saturating dressings will ease the removal by loosening adherents and
decreasing pain, especially with burns.
5. Monitor patient’s continence status and minimize exposure of skin

impairment site and other areas to moisture from incontinence,
perspiration, or wound drainage.
Prevents exposure to chemicals in urine and stool that can strip or erode the skin
causing further impaired tissue integrity.
6. If the patient is incontinent, implement an incontinence management
plan.
Prevent exposure to chemicals in urine and stool that can strip or erode the skin.
7. Check every two (2) hours for proper placement of footboards,

restraints, traction, casts, or other devices, and assess skin and tissue
integrity.
Mechanical damage to skin and tissues (pressure, friction, or shear) is often
associated with external devices.
8. Pay special attention to all high-risk areas such as bony prominences, skin
folds, sacrum, and heels.
Systematic inspection can identify impending problems early and provide early
treatment.
9. Identify a plan for debridement when necrotic tissue (eschar or slough) is

present and if compatible with overall patient management goals
Healing does not transpire in the appearance of necrotic tissue.
10. Encourage the use of pillows, foam wedges, and pressure-reducing

devices.
To prevent pressure injury.
11. Administer antibiotics as ordered.

Although intravenous antibiotics may be indicated, wound infections may be
managed well and more efficiently with topical agents.
12. Tell the patient to avoid rubbing and scratching. Provide gloves or clip
the nails if necessary.
Rubbing and scratching can cause further injury and delay healing.
13. Encourage a diet that meets nutritional needs.

A high-protein, high-calorie diet may be needed to promote healing.
14. Discuss the relationship between adequate nutrition consisting of fluids,

protein, vitamins B and C, iron, and calories.
Nutrition plays a vital role in maintaining intact skin and in promoting wound
healing.
15. For patients with limited mobility, use a risk assessment tool to assess
immobility-related risk factors systematically.
Identifies the patient’s risk for immobility-related skin breakdown.
16. Do not position the patient on the site of impaired tissue integrity. If
ordered, turn and position the patient at least every two (2) hours and
carefully transfer the patient.
This is to avoid the adverse effects of external mechanical forces (pressure,
friction, and shear).
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17. Maintain the head of the bed at the lowest degree of elevation possible.
To reduce shear and friction.
18. Educate patient about proper nutrition, hydration, and methods to

maintain tissue integrity.
The patient needs proper knowledge of their condition to prevent impaired tissue
integrity.
19. Teach skin and wound assessment and ways to monitor for signs and
symptoms of infection, complications, and healing.
Early assessment and intervention help prevent the development of serious
problems.
20. Instruct patient, significant others, and family in the proper care of the
wound, including handwashing, wound cleansing, dressing changes, and
application of topical medications).
Accurate information increases the patient’s ability to manage therapy
independently and reduces the risk for infection.
21. Educate the patient on the need to notify the physician or nurse.
This is to prevent further impaired tissue integrity complications.

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CLINT S.

Nursing Interventions and Rationales

1. Provide tissue care as needed.

2. Keep a sterile dressing technique during wound care.

3. Premedicate for dressing changes as necessary.

4. Wet the dressings thoroughly with sterile normal saline solution before

5. Monitor patient’s continence status and minimize exposure of skin

7. Check every two (2) hours for proper placement of footboards,

9. Identify a plan for debridement when necrotic tissue (eschar or slough) is

10. Encourage the use of pillows, foam wedges, and pressure-reducing

11. Administer antibiotics as ordered.

13. Encourage a diet that meets nutritional needs.

14. Discuss the relationship between adequate nutrition consisting of fluids,

18. Educate patient about proper nutrition, hydration, and methods to

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