Goals and Outcomes

The following are the common goals and expected outcomes for impaired tissue
integrity. Use them in writing your short term or long term goals for your
impaired tissue integrity 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.
 Assessment is required to recognize possible problems that may have lead
to Impaired 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.
 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.
 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
skincare 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.