Skin integrity may also be broken as a result of shearing or friction injury. The nursing diagnosis Risk for Impaired Skin Integrity is defined as at risk for skin being adversely altered. impaired tissue integrity a nursing diagnosis accepted by the North American Nursing Diagnosis Association, defined as a state in which an individual has damage to a mucous membrane or to corneal, integumentary, or subcutaneous tissue. The skin is the largest organ in the human body and is a protective barrier. The damage may also occur to corneal, subcutaneous or integumentary tissue. The skin, cornea, subcutaneous tissues, and mucous membranes act as a physical barrier preventing penetration against threats from the external environment. The nursing diagnosis of Impaired Tissue Integrity is defined as damage to mucous membrane, corneal, integumentary, or subcutaneous tissues.Use this guide to help develop your Impaired Tissue Integrity care plan. Pay special attention to all high-risk areas such as bony prominences, skin folds, sacrum, and heels. Use this guide to develop your impaired skin integrity nursing care plan.
Determine whether client is experiencing changes in sensation or pain. 4. The epidermis is not intact and layers below the skin like the dermis and bone may be visible.
Monitor site of impaired tissue integrity at least once daily for color changes, redness, swelling, warmth, pain, or other signs of infection. Impaired skin integrity : Breakdown in skin primarily due to impaired blood supply as a result of prolonged pressure on the tissue. Impaired tissue integrity occurs when a person suffers damage to the mucous membrane.