KEY ISSUES DESIRED INTERVENTIONS ACTUAL

OUTCOMES OUTCOMES
Impaired tissue Integrity related Following a 3- INDEPENDENT: After 3 days  of
to debridement and removal of day nursing 1. Inspect the nursing student -
implantations on left leg intervention, incision every patient interaction
the client will: shift using the patient was
Subjective: REEDA able to:
1. Patient verbalized pain -Describe (redness, -Verbalize pain
score of 1/10 located at measures to edema, score of 0/10
left leg. protect and heal ecchymosis, located at left leg
Objective: the tissue, discharge, and -Report no
1. 1x1cm ulcer on lateral including wound approximation) decrease and
aspect of left knee w/ pus care. Rationale: This increase in wound
discharge, and 3x3cm provides size and no
lesion on medial aspect -Report information increase in
of left leg w/ black decrease in regarding skin granulation of
discoloration, swelling, wound size and circulation and tissues
and bleeding noted. increase in problems that may - Describe
Scientific Basis: Damage to granulation of be caused by measures to protect
mucous membrane, corneal, tissue. application or and heal the tissue,
integumentary, or subcutaneous restriction of cast, including wound
tissues. -Verbalize relief splint or traction care.
Source: Wayne, G., Wayne, G., of discomfort apparatus, or - Demonstrate
& Wayne. (2019, March 20). edema formation behaviors/technique
Impaired Tissue (Skin) Integrity -Demonstrate that may require s to prevent skin
– Nursing Diagnosis & Care behaviors/techni further medical breakdown/facilitate
Plan. Retrieved from ques to prevent intervention. healing as indicated
https://nurseslabs.com/impaired skin Frequent
-tissue-integrity/ breakdown/facili assessment can
tate healing as detect early signs
indicated and symptoms of
infection.
-Achieve timely 2. Reposition
wound/lesion patient
healing if frequently and
present keep leg
elevated.
Rationale: Lessens
constant pressure
on the same areas
and minimizes the
risk of skin
breakdown.
Elevation may
reduce the risk of
abrasions to
elbows and heels.
3. Provide
optimum
nutrition
including
vitamins such
as Vit. C and E
Rationale: To
provide a positive
nitrogen balance to
aid in skin/tissue
healing and
maintain general
good health
4. Encourage
early
ambulation or
mobilization
Rationale: To
promote circulation
and reduces risks
associated with
immobility.
5. Administer
antibiotics as
ordered.
Rationale: Wound
infections may be
managed well and
more efficiently
with topical agents,
although
intravenous
antibiotics may be
indicated.
Collaborative:
1. Instruct patient
and S.O. to
cleanse the skin
with soap and
water and pat
incision site dry
every after
bathing.
Rationale:
Reduces the level
of contaminants on
the skin. Proper
care of incisions
promotes healing,
reduces scarring,
and reduces the
risk of an infection.
2. Instruct patient,
SOs, and family
in the proper
care of the
wound,
including hand
washing, wound
cleansing,
dressing
changes, and
application (of
topical
medications).
Rationale:
Accurate
information
increases the
patient’s ability to
manage therapy
independently and
further reduce the
risk for infection.
3. Educate patient
and SOs about
proper nutrition,
hydration, and
methods to
maintain tissue
integrity.
Rationale: The
patient and SOs
need proper
knowledge of his or
her condition to
prevent impaired
tissue integrity.
4. Tell patient and
SOs to avoid
rubbing and
 scratching.
Provide gloves
or clip the nails
if necessary.
Rationale:
Rubbing and
scratching can
cause further injury
and delay healing.
5. Educate the
patient and SOs
the need to
notify the
physician or
nurse.
Rationale: This is
to prevent further
impaired tissue
integrity
complications.