·Reports any altered sensation or pain at site of tissue impairment
·Demonstrates understanding of plan to heal tissue and prevent injury
·Describes measures to protect and heal the tissue, including wound care
·Wound decreases in size and has increased granulation tissue
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·Incision Site Care
·Pressure Ulcer Care
·Skin Care: Topical Treatments
Nursing Interventions and Rationales
·Assess site of impaired tissue integrity and determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, leg ulcer). Prior assessment of wound etiology is critical for proper identification of nursing interventions (van Rijswijk, 2001).
·Determine size and depth of wound (e.g., full-thickness wound, stage III or stage IV pressure ulcer). Wound assessment is more reliable when performed by the same caregiver, the client is in the same position, and the same techniques are used (Krasner, Sibbald, 1999; Sussman, Bates-Jensen, 1998).
·Classify pressure ulcers in the following manner:
oStage III: Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia; ulcer appears as a deep crater with or without undermining of adjacent tissue (National Pressure Ulcer Advisory Panel, 1989).
oStage IV: Full-thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures (e.g., tendons, joint capsules) (National Pressure Ulcer Advisory Panel, 1989).
·Monitor site of impaired tissue integrity at least once daily for color changes, redness, swelling, warmth, pain, or other signs of infection. Determine whether client is experiencing changes in sensation or pain. Pay special attention to all high-risk areas such as bony prominences, skin folds, sacrum, and heels. Systematic inspection can identify impending problems early (Bryant, 1999).
·Monitor status of skin around wound. Monitor client’s skin care practices, noting type of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing. Individualize plan according to client’s skin condition, needs, and preferences. Avoid harsh cleansing agents, hot water, extreme friction or force, or cleansing too frequently (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992; Bergstrom, 1994).
·Monitor client’s continence status and minimize exposure of skin impairment site and other areas to moisture from incontinence, perspiration, or wound drainage.
·If client is incontinent, implement an incontinence management plan to prevent exposure to chemicals in urine and stool that can strip or erode the skin. Refer to a physician (e.g., urologist, gastroenterologist) for an incontinence assessment (Doughty, 2000; Wound, Ostomy, and Continence Nurses Society, 1992, 1994).
·Monitor for correct placement of tubes, catheters, and other devices. Assess skin and tissue affected by the tape that secures these devices (Faller, Beitz, 2001). Mechanical damage to skin and tissues as a result of pressure, friction, or shear is often associated with external devices.
·In orthopedic clients, check every 2 hours for correct placement of foot boards, restraints, traction, casts, or other devices, and assess skin and tissue integrity. Be alert for symptoms of compartment syndrome (see care plan for Risk for Peripheral neurovascular dysfunction). Mechanical damage to skin and tissues (pressure, friction, or shear) is often associated with external devices.
·For clients with limited mobility, use a risk assessment tool to systematically assess immobility-related risk factors. A validated risk assessment tool such as the Norton or Braden scale should be used to identify clients at risk for immobility-related skin breakdown (Bergstrom et al, 1987; Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992; Krasner, Sibbald, 1999).
·Implement a written treatment plan for topical treatment of the skin impairment site. A written treatment plan ensures consistency in care and documentation (Maklebust, Sieggreen, 1996). Topical treatments must be matched to the client, wound, and setting (Krasner, Sibbald, 1999; Ovington, 1998).
·Identify a plan for debridement if necrotic tissue (eschar or slough) is present and if consistent with overall client management goals. Healing does not occur in the presence of necrotic tissue (Panel for the Prediction and Prevention of Pressure ulcers in Adults, 1992; Bergstrom et al, 1994; Krasner, Sibbald, 1999).
·Select a topical treatment that maintains a moist wound-healing environment that is balanced with the need to absorb exudate and fill dead space. Caution should always be taken to not dry out the wound (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992; Bergtrom et al, 1994; Ovington, 1998).
·Do not position client on site of impaired tissue integrity. If consistent with overall client management goals, turn and position client at least every 2 hours, and carefully transfer client to avoid adverse effects of external mechanical forces (pressure, friction, and shear). Evaluate for use of specialty mattresses, beds, or devices as appropriate (Fleck, 2001). If the goal of care is to keep the client (e.g., a terminally ill client) comfortable, turning and repositioning may not be appropriate. Maintain the head of the bed at the lowest degree of elevation possible to reduce shear and friction, and use lift devices, pillows, foam wedges, and pressure-reducing devices in the bed (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992; Krasner, Rodeheaver, Sibbald, 2001).
·Avoid massaging around site of impaired tissue integrity and over bony prominences. Research suggests that massage may lead to deep-tissue trauma (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).
·Assess client’s nutritional status; refer for a nutritional consultation and/or institute dietary supplements. Inadequate nutritional intake places the client at risk for skin breakdown and compromises healing (Demling, De Santi, 1998).
Home Care Interventions
·Instruct and assist client and caregivers with removing or controlling impediments to wound healing (e.g., management of underlying disease, improvement in approach to client positioning, improved nutrition). Wound healing can be delayed or fail totally if impediments are not controlled (Krasner, Sibbald, 1999).
·Initiate a consultation in a case assignment with a wound, ostomy, continence nurse (WOC nurse) to establish a comprehensive plan as soon as possible.
·Teach skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing. Early assessment and intervention helps prevent the development of serious problems (van Rijswijk, 2001).
·Teach use of a topical treatment that is matched to client, wound, and setting. The topical treatment needs to be adjusted as the status of the wound changes (Krasner, Sibbald, 1999).
·If consistent with overall client management goals, teach how to turn and reposition client at least every 2 hours. If the goal of care is to keep the client (e.g., a terminally ill client) comfortable, turning and repositioning may not be appropriate (Krasner, Rodeheaver, Sibbald, 2001; Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).
·Teach use of pillows, foam wedges, and pressure-reducing devices to prevent pressure injury.
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