Wound Care and Skin/Tissue Integrity Nursing Care Plan

For this nursing care plan and management guide learn how to provide care for patients with wounds or break in their tissue/skin integrity. Get to know the nursing assessment, interventions, goals, and nursing diagnosis for impairment in tissue integrity.

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What is tissue integrity?

What constitutes our body’s protection against external threats? Yes, it’s the integumentary system. Specifically, our skin, cornea, subcutaneous tissues, and mucous membranes are our first line of defense against threats from the external environment. In a normal setting, these defenses are adequate to defend the body from any threats. However, some factors may cause impairment or a break in this line of defense, causing impairment of tissue integrity.

The most common cause includes physical trauma (e.g., car accidents, sports injuries, cuts, blunt trauma, etc.). Other causes can be related to thermal factors (e.g., burns, frostbites), or chemical injury (e.g., adverse reactions to drugs), infection, nutritional imbalances, fluid imbalances, and altered circulation (e.g., pressure ulcers).

A break in tissue integrity is usually repaired by the body very well. However, there are circumstances that it doesn’t repair it at all and replaces the damaged tissue with connective tissue. When tissue integrity is left untreated, it could cause local or systemic infection and ultimately lead to necrosis.

Other factors include age, weight loss, poor nutrition and hydration, excessive moisture and dryness, smoking, and other conditions affecting blood flow.

Signs and symptoms

A break in tissue integrity is characterized by the following subjective and objective data:

• Affected area hot, tender to touch
• Damaged or destroyed tissue (e.g., cornea, mucous membranes, integumentary, subcutaneous)
• Local pain
• Protectiveness toward site
• Skin and tissue color changes (red, purplish, black)
• Swelling around the initial injury

Goals and outcomes

The following are the common goals and expected outcomes for wound care and break in tissue integrity. Use them in writing your short term or long term goals for your care plan:

• Patient reports any altered sensation or pain at site of tissue impairment.
• Patient demonstrates understanding of plan to heal tissue and prevent injury.
• Patient describes measures to protect and heal the tissue, including wound care.
• Patient’s wound decreases in size and has increased granulation tissue.

Nursing assessment and rationales

Assessment is required to recognize possible problems that may have lead to a break in tissue integrity and identify any episode that may transpire during nursing care.

1. Determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, leg ulcer).
Prior assessment of wound etiology is critical for the proper identification of nursing interventions that will guide nursing care.

2. Assess the site of impaired tissue integrity and its condition.
Redness, swelling, pain, burning, and itching are indications of inflammation and the body’s immune system response to localized tissue trauma or impaired tissue integrity.

3. Assess characteristics of the wound, including color, size (length, width, depth), drainage, and odor.
These findings will give information on the extent of the impaired tissue integrity or injury. Pale tissue color is a sign of decreased oxygenation. An odor may result from the presence of infection on the site; it may also be coming from necrotic tissue. Serous exudate from a wound is a normal part of inflammation and must be differentiated from pus or purulent discharge present in the infection.

4. Assess changes in body temperature, specifically increased body temperature.
Fever is a systemic manifestation of inflammation and may indicate the presence of infection.

5. Assess the patient’s level of pain.
Pain is part of the normal inflammatory process. The extent and depth of injury may affect pain sensations.

For more information about pain, please visit: Acute Pain Nursing Care Plan and Management

6. Monitor site of impaired tissue integrity at least once daily for color changes, redness, swelling, warmth, pain, or other signs of infection.
Systematic inspection can identify impending problems early.

7. Monitor the status of the skin around the wound. Monitor patient’s skin care practices, noting the type of soap or other cleansing agents used, the temperature of the water, and frequency of skin cleansing.
Individualize plan is necessary according to the patient’s skin condition, needs, and preferences.

8. Know signs of itching and scratching.
The patient who scratches the skin to alleviate extreme itching may open skin lesions and increase the risk for infection.

9. Assess patient’s nutritional status; refer for a nutritional consultation or institute dietary supplements.
Inadequate nutritional intake places the patient at risk for skin breakdown and compromises healing, causing impaired tissue integrity.

10. Classify pressure ulcers by assessing the extent of tissue damage.
According to the National Pressure Ulcer Advisory Panel, wound assessment is more reliable when classified in such a manner. The following are the stages of pressure ulcers:

• Stage I. Nonblanchable erythema signaling potential ulceration.
• Stage II. Partial-thickness skin loss (abrasion, blister, or a shallow crater) involving the epidermis and may extend through the dermis.
• Stage 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.
• Stage IV. Full-thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures (e.g., tendons, joint capsules)

See also: Pressure Ulcers Nursing Care Plans

11. Monitor for proper placement of tubes, catheters, and other devices. Assess skin and tissue affected by the tape that secures these devices.
Mechanical damage to skin and tissues due to pressure, friction, or shear is often associated with external devices.

1. Assess the overall condition of the skin.
Assessment of the condition of the skin provides baseline data for possible interventions for the nursing diagnosis Risk for Impaired Skin Integrity. Normal skin condition differs among individuals. Healthy skin should have good turgor (an indication of moisture), feel warm and dry to the touch, be free from impairment (cuts, wounds, abrasions, excoriation, outbreaks, and rashes), and have quick capillary refill (less than 6 seconds). Patients with advanced age are at high-risk risk for skin impairment because the skin is less elastic, has less moisture, and has thinning of the epidermis.

2. Assess for history or presence of AIDS or other immunological problems.
Skin lesions or Kaposi’s sarcoma is an early manifestation of diseases related to HIV.

3. Assess for a history of radiation therapy.
Radiated skin becomes thin and friable, may have less blood supply, and is at higher risk for breakdown.

4. Check on bony prominences such as the sacrum, trochanters, scapulae, elbows, heels, inner and outer malleolus, inner and outer knees, back of the head).
Specific areas where the skin is stretched tautly are at higher risk for breakdown because the possibility of ischemia to the skin is high as a result of compression of skin capillaries between a hard surface (e.g., mattress, chair, or table) and the bone. For lightly pigmented skin, pressure areas appear to be red. For darker skin tones, these areas appear to be red, blue, or purple hue spots.

5. Evaluate the patient’s awareness of the sensation of pressure.
Usually, individuals change position off pressure areas every few minutes; these occur automatically even during sleep. Patients who are unaware of sensation tend to do nothing thus results in prolonged pressure on skin capillaries and eventually in skin ischemia.

6. Use an objective tool for pressure ulcer risk assessment.
These are validated tools for risk assessment.

• Acute care: Assessment should be every 24 to 48 hours or sooner if the patient’s condition changes.
• Long-term care: Assess on admission, weekly for 4 weeks, and then quarterly and whenever resident’s condition changes.

• Braden Scale
  This is a widely used scale. It consists of six subscales: sensory, perception, moisture, activity and mobility, nutrition, and friction/shear.
• Norton scale
  This system remains popular due to its ease of use. It includes the assessment of physical condition, mental condition, activity, mobility, and incontinence.

7. Evaluate the patient’s strength to move (e.g., shift weight while sitting, turn over in bed, move from bed to chair).
The greatest risk factor in skin breakdown is immobility.

8. Assess the patient’s nutritional status, including weight, weight loss, and serum albumin levels.
An albumin level less than 2.5 g/dL is a grave sign, indicating severe protein depletion and a high risk of skin breakdown.

9. Assess for fecal/urinary incontinence.
Stools may contain enzymes that cause skin breakdown. The urea in urine turns into ammonia within minutes and is caustic to the skin. The use of diapers and incontinence pads hastens skin breakdown.

10. Assess for edema.
Skin tightened tautly over edematous tissue is at risk for impairment.

11. Assess the amount of shear (pressure exerted laterally) and friction (rubbing) on the patient’s skin.
A typical cause of shear is elevating the head of the patient’s bed: the body’s weight is displaced downward onto the patient’s sacrum. Typical causes of friction include the patient rubbing heels or elbows against bed linen, and moving the patient up in bed without the use of a lift sheet.

12. Assess the surface that the patient consumes most of his or her time on (e.g., mattress for a bedridden patient, cushion for people in wheelchairs).
Patients who spend the majority of their time on one surface require a pressure reduction or pressure relief device to distribute pressure more evenly and reduce the risk for breakdown.

13. Assess for environmental moisture (e.g., wound drainage, high humidity).
Moisture may contribute to skin maceration.

14. Assess the skin for Dermatitis or exposure to chemical irritants
These conditions can cause inflammation, resulting in redness and itching, and may cause blisters.

15. Assess the skin for Pruritus (itching) or mechanical trauma
Itching or mechanical traumas can result in disruptions to skin integrity and reduce its barrier function.

16. Assess the skin for signs of Long-term steroid use.
Long-term steroid use may leave skin papery thin and prone to injury.

17. Reassess the skin regularly and whenever the patient’s condition

Nursing interventions and rationales

The following are the therapeutic nursing interventions and actions for wound care and breakdown of skin integrity.

1. Provide wound/skin 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.

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.
These measures help redistribute and relieve pressure and 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).

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 patient and caregiver about 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.

1. Discourage the patient or caregiver from elevating the head of the bed repeatedly.  Encourage the use of lifting devices like trapeze or bed linen to move the patient in bed.
The common cause of impaired skin integrity is friction which involves rubbing heels or elbows toward bed linen and moving the patient up in bed without the use of a lift sheet. A common cause of shear is elevating the head of the patient’s bed: the body’s weight is shifted downward onto the patient’s sacrum.

2. Encourage the patient to change position every 15 minutes and change chair-bound positions every hour.
During sitting, the pressure over the sacrum may exceed 100 mm Hg. The pressure needed to close capillaries is around 32 mm Hg; any pressure above 32 mm Hg leads to ischemia.

3. Encourage the implementation of pressure-relieving devices commensurate with the degree of risk for skin impairment:

• 3.1. For low-risk patients: good-quality (dense, at least 5 inches thick) foam mattress overlay
  Egg crate-type mattresses less than 4 to 5 inches thick do not relieve pressure. Because they are made of foam, moisture can be trapped. A false sense of security with the use of these mattresses can delay initiation of devices useful in relieving pressure.
  
• 3.2. For moderate-risk patients: water mattress, static or dynamic air mattress
  Dynamic devices electronically alternate inflation and deflation of the device. Static devices consist of gel, foam, water, or air that remains in a constant state of inflation. In the home, a waterbed is a good alternative.
  
• 3.3. For high-risk patients or those with existing stage III or IV pressure ulcers (or with stage II pressure ulcers and multiple risk factors): low-air-loss beds (Mediscus, Flexicare, KinAir) or air-fluidized therapy (Clinitron, Skytron)
  Low-air-loss beds allow elevated head of bed and patient transfer. These should be used when pulmonary concerns necessitate elevating the head of bed or when getting the patient up is feasible. Air-fluidized therapy supports the patient’s weight at well below capillary closing pressure but restricts getting the patient out of bed easily.

4. Encourage the implementation of a turning schedule, restricting time in one position to 2 hours or less, if the patient is restricted to bed.
Turning every 2 hours is the key to prevent breakdown. Head of bed should be kept at 30 degrees or less to avoid sliding down on the bed.

5. Use pillows or foam wedges to keep bony prominences from direct contact with each other. Keep pillows under the heels to raise off the bed.
These measures reduce shearing forces on the skin.

6. Encourage ambulation if the patient is able.
Ambulation reduces pressure on the skin from immobility thus lessening the factors that may result in impaired skin integrity.

7. Encourage adequate nutrition and hydration:

• 2,000 to 3,000 kcal/day (more if increased metabolic demands)
• Fluid intake of 2000 mL/day unless medically restricted.

Sufficient hydration and nutrition help maintain skin turgor, moisture, and suppleness, which provide resilience to damage caused by pressure. Patients with a limited cardiovascular reserve may not be able to tolerate much fluid.

8. Clean, dry, and moisturize skin, particularly bony prominences, twice daily or as indicated by incontinence or sweating. Avoid hot water. If a powder is desirable, use medical-grade cornstarch; avoid talc.
Smooth, supple skin is more resistant to injury. These measures prevent evaporation away from the skin. Avoid talc which may cause lung injury.

9. Wrap blisters with gauze or apply a hydrocolloid dressing.
This prevents skin from harmful pathogens.

10. Massage only around the affected area.
This is to increase tissue perfusion. Massaging the actual reddened area may damage the skin further.

11. Educate patient and caregiver about the causes of pressure.
This information can assist the patient or caregiver in finding methods to prevent skin breakdown.

12. Reinforce the importance of turning, mobility, and ambulation.
These will enhance their sense of efficacy and can improve compliance with the prescribed interventions.

13. Educate patients and caregivers about proper skin care.
Educating patients and caregivers on methods to maintain skin integrity enhances their sense of self-efficacy and prevents skin breakdown.

14. Communicate with a dietician as appropriate.
The dietician can aid the patient and family in food preferences to meet adequate nutritional and hydration goals.

15. Communicate with a wound, ostomy, and continence nurse (WOCN).
The WOCN can assist staff, patients, and families in product selection, education, and the development of a prevention plan.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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See also

Other recommended site resources for this nursing care plan:

• Nursing Care Plans (NCP): Ultimate Guide and Database ^{MUST READ!}
  Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
• Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
  Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.

References and Sources

Recommended resources for the wound care and tissue integrity nursing care plan:

1. Baranoski, S., & Ayello, E. A. (2008). Wound care essentials: Practice principles. Lippincott Williams & Wilkins.
2. Berman, A., Snyder, S. J., Kozier, B., Erb, G. L., Levett-Jones, T., Dwyer, T., … & Parker, B. (2014). Kozier & Erb’s Fundamentals of Nursing Australian Edition (Vol. 3). Pearson Higher Education AU.
3. Corbett, L. Q. (2012). Wound care nursing: professional issues and opportunities. Advances in wound care, 1(5), 189-193.
4. Hardy, M. A. (1990). A pilot study of the diagnosis and treatment of impaired skin integrity: dry skin in older persons. International Journal of Nursing Terminologies and Classifications, 1(2), 57-63.
5. Iverson-Carpenter, M. S. (1988). Impaired skin integrity. Journal of geron
6. Kent, D. J., Scardillo, J. N., Dale, B., & Pike, C. (2018). Does the use of clean or sterile dressing technique affect the incidence of wound infection?. Journal of Wound, Ostomy and Continence Nursing, 45(3), 265-269.
7. Malaquias, S. G., Bachion, M. M., Martins, M. A., Nunes, C. A. D. B., Torres, G. D. V., & Pereira, L. V. (2014). Impaired tissue integrity, related factors and defining characteristics in persons with vascular ulcers. Texto & Contexto-Enfermagem, 23(2), 434-442.
8. Menna Barreto, L. N., Swanson, E. A., & de Abreu Almeida, M. (2016). Nursing outcomes for the diagnosis impaired tissue integrity (00044) in adults with pressure ulcer. International journal of nursing knowledge, 27(2), 104-110.
9. Menna Barreto, L. N., Silva, M. B. D., Engelman, B., Figueiredo, M. S., Rodríguez‐Acelas, A. L., Cañon‐Montañez, W., & Almeida, M. D. A. (2019). Evaluation of surgical wound healing in orthopedic patients with impaired tissue integrity according to nursing outcomes classification. International journal of nursing knowledge, 30(4), 228-233.
10. Mendham, J. E. (2004). Gabapentin for the treatment of itching produced by burns and wound healing in children: a pilot study. Burns, 30(8), 851-853.
11. Murphy, J. V., Banwell, P. E., Roberts, A. H., & McGrouther, D. A. (2000). Frostbite: pathogenesis and treatment. Journal of Trauma and Acute Care Surgery, 48(1), 171.
12. Pezzi, M. V., Rabelo‐Silva, E. R., Paganin, A., & de Souza, E. N. (2016). Nursing Interventions and Outcomes for the Diagnosis of Impaired Tissue Integrity in Patients After Cardiac Catheterization: Survey. International journal of nursing knowledge, 27(4), 215-219.
13. Ratliff, C. (1990). Impaired skin integrity related to radiation therapy. Journal of enterostomal therapy, 17(5), 193.
14. Piloian, B. B. (1992). Defining characteristics of the nursing diagnosis” high risk for impaired skin integrity”. Decubitus, 5(5), 32-4.