tissue integrity

tissue integrity

the ability of body tissues to regenerate and/or repair to maintain normal physiological processes

scope of tissue integrity

intact

impaired

assessment findings in someone with impaired tissue integrity

dehydrated

chronic condition (diabetes)

rashes

open wounds

complications of impaired tissue integrity

impaired thermoregulation

altered elimination

impaired safety

altered body image

infant considerations

thin skin

prone to infection

gerontological considerations

natural health decline

decreased elasticity (wrinkly)

primary prevention

stay hydrated

protection from UV

nutrition

exercise

screenings

braden scale

ABCDE for melanoma

biopsy

tertiary

medications/antibiotics

wound care

education (hand hygiene, eat protein)

nursing interventions for impaired tissue integrity

hand hygiene

braden scale

positioning/turning every 2 hours

early ambulation

nutrition

cleaning (wounds/bandages)

dehiscence

reopening of a wound that was closed

evisceration

expulsion of organs from the body

wound assessment, NERDS

N on-healing

E xudative (fluid coming out)

R ed/bleeding

D ebris

S mell

wound assessment, STONEES

S ize is bigger

T emperature increased

O S, bone is showing

N ew area of breakdown

E xudate

E rythmea (red patches) OR edema

S mell