Impaired Tissue Integrity

1. Forces that cause skin breakdown.

1. Pressure.

2. Friction.

3. Shearing (combination of pressure and friction).

4. Excessive moisture.

2. Factors that contribute to skin breakdown.

1. Immobilization.

2. Edema.

3. Poor nutrition.

4. Decreased sense of pain.

5. Advanced age.

6. Incontinence.

7. Impaired circulation.

8. Moisture.

9. Other:                      

3. Areas most prone to breakdown.

1. Bony prominence such as sacrum, heels, hips, etc.

2. Warm moist areas such as under breasts, groin area, etc.

4. Basic principles of skin care.

1. The force causing the breakdown should be eliminated or decreased.

1. Use pressure relief devices such as eggcrate mattress, elbow and heel protectors, alternating pressure pads, sheepskin, etc.

2. Change position at least every two hours.

3. Keep linens wrinkle and crumb free.

4. Client should be moved with a draw sheet to prevent shearing action.

2.   Cleanliness of the wound is essential for healing.

1. Meticulous hygiene is essential.

2. Wash carefully and pat dry.

3. Debride wound if necessary.

3. Adequate circulation and nutrition are required for the healing process to occur.

1. Eat a well-balanced diet high in vitamins, protein, and minerals.

2. Exercise to improve circulation by bringing nutrients to the wound.

3. Avoid alcohol and cold temperatures, which constrict blood vessels.

4. A controlled, moist environment promotes healing.

1. Use devices such as bioclusive, hydroculloidals, etc., as ordered by physician.

2. Lubricate dry skin.

3. Use an ointment to protect skin from excessive moisture and incontinence.

5. Possible complications of impaired tissue integrity.

1. Infection of wound.

2. Septicemia.