Impaired Tissue Integrity & WoUND CARE: A nursing care plan for patients with a wound is critical to their recovery. Patients who have suffered an injury should be treated in a therapeutic environment free from friction, shearing, or pressure. Patients should also be encouraged to practice self-care to promote wound healing and reduce pain. This includes daily bathing, changing bedsheets at least twice a week, and turning every two hours.
Impaired Tissue Integrity
An Impaired Tissue Integrity & WoUND Care Nursing Case Plan describes nursing intervention for patients with a wound. This case plan should address the following:
Repair by the body
To determine the etiology of a patient’s wound, you must conduct an assessment. The wound’s depth, size, and granulation tissue are important factors. An assessment will be more accurate if the same caregiver performs it and uses the same techniques. The goal is to reduce the risk of infection while promoting healing. Additionally, patient education is essential. Impaired tissue integrity may be a sign of underlying health problems that require nursing care.
Local or systemic infection
Impaired tissue integrity entails the treatment of wounds with compromised integrity. This condition is characterized by redness, swelling, pain, itching, drainage, and odor. While the presence of any of these symptoms is not an indication of infection, they may indicate the presence of other, deeper injuries. Moreover, identifying the difference between pus and serous exudate is crucial.
Preoperative assessment should include determining the level of tissue damage and evaluating the patient’s skin and surrounding tissues. High-risk areas include bony prominences, skin folds, heels, and sacrum. Nutritional evaluations should be made as well, as inadequate nutrition can exacerbate the situation. Early identification of potential problems is important for determining proper nursing interventions and preventing further tissue damage.
To help patients heal properly, impaired tissue integrity requires an individual care plan. Patients should be monitored regularly, and pressure areas must be covered with white wool or sheepskin. Patients should also be encouraged to practice self-care methods to avoid further breakdown of the skin and promote wound healing. Self-care includes bathing, changing bed sheets every other day, and turning and moving frequently. Nursing care providers should use this assessment data to create an individual care plan based on the patient’s individual needs.