Nursing Diagnosis / Scientific Explanation
Problems in
Collaboration
Impaired skin The skin and these other
integrity r/t self- tissues are a physical barrier to
mutilation secondary prevent penetration of external
to BPD evidenced threats and harmful substances.
by lesions on both Impaired tissue integrity occurs evidenced by:
hands. when a person suffers damage
to the mucous membrane. The
damage may also occur to
corneal, subcutaneous or
integumentary tissue.
Altered skin integrity increases
the chance of infection, and
decreased function. Skin is
affected by both intrinsic and
extrinsic factors. Intrinsic
factors can include altered
nutritional status, vascular
disease issues, and diabetes.
Extrinsic factors include falls,
Expected Outcomes/ Nursing Interventions Rationale of the Evaluation
Nursing Objectives Interventions
Assessment:
The patient will be 1-Assess vital signs 1-Rise of temperature The patient was able to
able to display especially temperature. indicates infection. display improvement in
improvement in 2-Assess site of 2-Redness, swelling, wound healing as
wound healing as impaired tissue and its pain, burning, and evidenced by:
condition. indicate inflammation.
3-Assess characteristics 3-Pale tissue color is a -Intact skin and
-Intact skin and of wound (color, size, sign of decreased minimized presence of
minimized presence of drainage, odor). oxygenation. Odor may wounds and partially
wound and increase be a result of presence of increased granulation
granulation tissue. 4-Know signs of infection on the site. tissue.
itching and scratching. Serous exudates from
-Absence of itchiness, 5-Keep the wound care wound is a normal part -Absence of itchiness,
redness and no sign of sterile and dry. of inflammation and redness and no sign of
infection. 6-Assess patient’s must be differentiated infection.
nutritional status due to from pus or purulent
nutritional alteration. discharge which is Outcome partially
present in infection. met as the patient’s
Interventions: 4-The patient who hands are in progress
7-Apply Mebo on both scratches the skin to of healing showing no
hands. alleviate the sense of infection.
accidents, pressure, self- 8-Advise patient to extreme itching may
mutilation, self-harm, avoid rubbing and open skin lesion and
immobility, and surgical scratching. increase risk for
procedures. 9-Assess for pain at infection.
wound and any signs of 5-Moisture harbor
bleeding. microorganism.
10-Encourage protein 6-Risk for skin
and fiber diets that breakdown and
meets nutritional needs. compromises healing
11-Note lab results requires adequate
pertinent to causative proteins.
factors (Hgb/Hct, blood 7-To improve wound.
glucose, albumin) 8-Rubbing and
Teachings: scratching can cause
12-Instruct patient and further injury and delay
family members in healing.
proper wound care 9-Pain associated with
including hand bleeding indicates there
washing, wound is further tissue damage
cleaning and dressing and tearing.
changes. 10-High protein and
13-Educate the patient fiber diets promote
and her parents about healing and GI motility.
proper nutrition 11-To assess causative
hydration and methods factors.
 to maintain tissue 12-Reduce risk for
integrity. infection.
13-Prevents further
tissue injury.

Updated by V.G Fall 2017 Page 18