Risk for Unstable Blood Glucose

Risk for Unstable Blood Glucose: At risk for variation of blood glucose levels from the normal range that
may compromise health.

Risk factors

 Inadequate blood glucose monitoring

 Lack of adherence to diabetes management

 Medication management

 Deficient knowledge of diabetes management

 Developmental level

 Lack of acceptance of diagnosis

 Stress

 Sedentary activity level

 Insulin deficiency or excess

Possibly evidenced by

 [Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at prevention.]

Desired outcomes

 Patient has a blood glucose reading of less than 180 mg/dL; fasting blood glucose levels of less
than <140 mg/dL; and hemoglobin A1C level <7%.

Nursing Interventions Rationale

Hyperglycemia results when

there is an inadequate
amount of insulin to glucose.
Excess glucose in the blood
creates an osmotic effect that
Assess for signs of hyperglycemia. results in increased thirst,
hunger, and increased
urination. The patient may
also report nonspecific
symptoms of fatigue and
blurred vision.
 Blood glucose should be
between 140 to 180 mg/dL.
Assess blood glucose level before meals and at bedtime. Non-intensive care patients
should be maintained at pre-
meal levels <140 mg/dL.

This is a measure of blood

glucose over the previous 2 to
Monitor patient’s HbA1c-glycosylated hemoglobin.
3 months. A level of 6.5% to
7% is desirable.

These are signs of

Assess for anxiety, tremors, and slurring of speech. Treat hypoglycemia with 50%
hypoglycemia and D50 is
dextrose.
treatment for it.

To monitor peripheral
Assess feet for temperature, pulses, color, and sensation.
perfusion and neuropathy.

Nonadherence to dietary
guidelines can result in
Assess the patient’s current knowledge and understanding about the prescribed
hyperglycemia. An
diet.
individualized diet plan is
recommended.

Physical activity helps lower

blood glucose levels. Regular
exercise is a core part
Assess the pattern of physical activity.
of diabetes management and
reduces risk for cardiovascular
complications.

A patient with type 2 DM who

uses insulin as part of the
treatment plan is at increased
risk for hypoglycemia.
Manifestations of
hypoglycemia may vary
Monitor for signs of hypoglycemia. among individuals but are
consistent in the same
individual. The signs are
the result of both increased
adrenergic activity and
decreased glucose delivery to
the brain, therefore, the
patient may experienced
 tachycardia, diaphoresis,
dizziness, headache, fatigue,
and visual changes.

Adherence to the therapeutic

regimen promotes tissue
perfusion. Keeping glucose in
Administer basal and prandial insulin.
the normal range slows
progression of microvascular
disease.

Blood glucose is monitored

before meals and at bedtime.
Teach patient how to perform home glucose monitoring.
Glucose values are used to
adjust insulin doses.

Hypertension is commonly
associated with diabetes.
Report BP of more than 160 mm Hg (systolic). Administer hypertensive as Control of BP
prescribed. prevents coronary
artery disease, stroke,
retinopathy, and nephropathy.

Patients have decreased

Instruct patient to avoid heating pads and always to wear shoes when walking. sensation in the extremities
due to peripheral neuropathy.

Renal failure causes creatinine

>1.5 mg/dL. Microalbuminuria
Monitor urine albumin to serum creatinine for renal failure.
is the first sign of diabetic
nephropathy.

Instruct patient to take oral hypoglycemic medications as directed:

Stimulates insulin secretion by

the pancreas. They also
enhance cell receptor
 Sulfonylureas: glipizide (Glucotrol), glyburide (DiaBeta), glimepiride(Amaryl). sensitivity to insulin and
decrease the liver synthesis of
glucose from amino acids and
stored glycogen.

Stimulates insulin secretion by

 Meglitinides: repaglinide (Prandin)
the pancreas.
 These drugs decrease the
amount of glucose produced
by the liver and improve
 Biguanides: metformin (Glucophage)
insulin sensitivity. They
enhance muscle cell receptor
sensitivity to insulin.

Stimulates rapid insulin

secretion to reduce the
 Phenylalanine derivatives:nateglinide (Starlix)
increases in blood glucose that
occur soon after eating.

Delays the absorption of

 Alpha-glucosidase inhibitors:acarbose (Precose), miglitol (Glyset). glucose into the blood from
the intestine.

Drugs decrease insulin

 Thiazolidinediones: pioglitazone(Actos), rosiglitazone (Avandia) resistance in peripheral
tissues.

Increases insulin secretion and

 Incretin modifier: sitagliptinphosphate (Januvia)
decreases glucagon secretion.

Instruct patient to take insulin as directed

Have an onset of action within

15 minutes of administration.
 Rapid-acting insulin analogs: lisproinsulin (Humalog), insulin aspart The duration of action is 2 to 3
hours for Humalog and 3 to 5
hours for aspart.

Has an onset of action within

30 minutes of administration;
 Short-acting insulin: regular
duration of action is 4 to 8
hours.

Onset of action for the

intermediate-acting is one
 Intermediate-acting insulin: neutral protamine Hagedorn (NPH), insulin zinc
hour after administration;
suspension (Lente)
duration of action is 18 to 26
hours.

Premixed concentration has

 Intermediate and rapid: 70% NPH/30% regular. an onset of action similar to
that of rapid-acting insulin and
a duration of action similar to
 that of intermediate-acting
insulin.

Have an onset of one hour

after administration. Duration
of action is 36 hours for
 Long-acting insulin: Ultralente, insulin glargine (Lantus)
Ultralente is 36 hours and
for glargine is at least 24
hours.

Instruct the patient on the proper preparation and administration of insulin.

Absorption of insulin is more

consistent when insulin is
always injected in the same
anatomical site. Absorption if
fastest in the abdomen,
followed by the arms, thighs,
 Injection procedures.
and buttocks. It is
recommended by the
American Diabetes Association
to administer insulin into the
subcutaneous tissue of the
abdomen.

Injection of insulin in the same

site over time will result in
 Rotation of injection within one anatomical site. lipoatrophy and
lipohypertrophy with reduced
insulin absorption.

Insulin should be refrigerated

at 2º to 8º C (36º to 46º F).
Unopened vials may be stored
until their expiration date. To
prevent irritation from “cold
 Storage of insulin.
insulin,” vials may be stored at
temperatures of 15º to 30ºC
(59º to 86ºF) for 1 month.
Opened vials are to be
discarded after that time.
Risk for Infection

Risk for Infection: At increased risk for being invaded by pathogenic organisms.

Nursing Diagnosis

 Risk for Infection

Risk factors may include

 High glucose levels, decreased leukocyte function, alterations in circulation

 Preexisting respiratory infection, or UTI

Possibly evidenced by

 [Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at prevention.]

Desired Outcomes

 Identify interventions to prevent/reduce risk of infection.

 Demonstrate techniques, lifestyle changes to prevent development of infection.

Nursing Interventions Rationale

Observe for the signs of infection and Patients with DM may be admitted with infection,
inflammation: fever, flushed appearance, wound which could have precipitated the ketoacidotic state.
drainage, purulent sputum, cloudy urine. They may also develop nosocomial infection.

Teach and promote good hand hygiene. Reduces risk of cross-contamination.

Maintain asepsis during IV insertion, administration of

Increased glucose in the blood creates an excellent
medications, and providing wound or site care. Rotate
medium for bacteria to thrive.
IV sites as indicated.

Minimizes risk of UTI. Comatose patient may be at

particular risk if urinary retention occurred before
Provide catheter or perineal care. Teach female
hospitalization. Note: Elderly female diabetic patients
patients to clean from front to back after elimination.
are especially prone to urinary tract and/or vaginal
yeast infections.

Peripheral circulation may be ineffective or impaired,

Provide meticulous skin care: gently massage bony
placing the patient at increased risk for skin breakdown
areas, keep skin dry. Keep linens dry and wrinkle-free.
and infection.
Nursing Interventions Rationale

Rhonchi may indicate accumulation of secretions

possibly related to pneumonia or bronchitis. Crackles
Auscultate breath sounds.
may results from pulmonary congestion or edema from
rapid fluid replacement or heart failure.

Place in semi-Fowler’s position. Facilitates lung expansion; reduces risk of aspiration.

Reposition and encourage coughing or deep breathing Aids in ventilating all lung areas and mobilizing
if patient is alert and cooperative. Otherwise, suction secretions. Prevents stasis of secretions with increased
airway using sterile technique as needed. risk of infection.

Provide tissues and trash bag in a convenient location

for sputum and other secretions. Instruct patient in To minimizes spread of infection.
proper handling of secretions.

Encourage and assist with oral hygiene. Reduces risk of oral/gum disease.

Decreases susceptibility to infection. Increased urinary

flow prevents stasis and aids in
Encourage adequate dietary and fluid intake
maintaining urine pH/acidity, reducing bacteria growth
(approximately 3000 mL/day if not contraindicated by
and flushing organisms out of system. Note: Use of
cardiac or renal dysfunction), including 8 oz of
cranberry juice can help prevent bacteria from
cranberry juice per day as appropriate.
adhering to the bladder wall, reducing the risk of
recurrent UTI.
Imbalanced Nutrition: Less Than Body Requirements

Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients insufficient to meet metabolic
needs.

Nursing Diagnosis

 Imbalanced Nutrition: Less Than Body Requirements

May be related to

 Insulin deficiency (decreased uptake and utilization of glucose by the tissues, resulting in
increased protein/fat metabolism)

 Decreased oral intake: anorexia, nausea, gastric fullness, abdominal pain; altered consciousness

 Hypermetabolic state: release of stress hormones (e.g., epinephrine, cortisol, and growth
hormone), infectious process

Possibly evidenced by

 Increased urinary output, dilute urine

 Reported inadequate food intake, lack of interest in food

 Recent weight loss; weakness, fatigue, poor muscle tone

 Diarrhea

 Increased ketones (end product of fat metabolism)

Desired Outcomes

 Ingest appropriate amounts of calories/nutrients.

 Display usual energy level.

 Demonstrate stabilized weight or gain toward usual/desired range with normal laboratory
values.

Nursing Interventions Rationale

Weighing serves as an assessment tool to determine

Weigh daily or as ordered.
the adequacy of nutritional intake.

Ascertain patient’s dietary program and usual pattern Identifies deficits and deviations from therapeutic
then compare with recent intake. needs.

To determine what information to be provided to client

Ascertain understanding of individual nutritional needs.
or SO.
Nursing Interventions
Discuss eating habits and encourage diabetic diet
(balanced diet) as prescribed by the doctor.
Document actual weight, do not estimate. Note total
daily intake including patterns and time of eating.
Consult dietician and/or physician for further
assessment and recommendation regarding food
preferences and nutritional support.
Auscultate bowel sounds. Note reports of
abdominal pain, bloating, nausea, vomiting of
undigested food. Maintain NPO status as indicated.
Provide liquids containing nutrients and electrolytes as
soon as patient can tolerate oral fluids then progress to
a more solid food as tolerated.
Identify food preferences, including ethnic and cultural
needs.
Include SO in meal planning as indicated.
Observe for signs of hypoglycemia: changes in LOC,
cold and clammy skin, rapid pulse, hunger,
irritability, anxiety, headache, lightheadedness,
shakiness.
Rationale
To achieve health needs of the patient with the proper
food diet for his condition.
Patients may be unaware of their actual weight or
weight loss due to estimation of weight.
To reveal changes that should be made in the client’s
dietary intake. For greater understanding and further
assessment of specific foods.
Hyperglycemia and fluid and electrolyte disturbances
can decrease gastric motility and/or function (due to
distention or ileus) affecting choice of interventions.
Note: Chronic difficulties with decreased gastric
emptying time and poor intestinal motility may suggest
autonomic neuropathies affecting the GI tract and
requiring symptomatic treatment.
Oral route is preferred when patient is alert and bowel
function is restored.
If patient’s food preferences can be incorporated into
the meal plan, cooperation with dietary requirements
may be facilitated after discharge.
To promote sense of involvement and provide
information to the SO to understand the nutritional
needs of the patient. Note: Various methods available
or dietary planning include exchange list, point system,
glycemic index, or pre selected menus.
Hypoglycemia can occur once blood glucose level is
reduced and carbohydrate metabolism resumes and
insulin is being given. If the patient is comatose,
hypoglycemia may occur without notable change in
LOC. This potentially life-threatening emergency should
be assessed and treated quickly per protocol. Note:
Type 1 diabetics of long standing may not display usual
signs of hypoglycemia because normal response to low
blood sugar may be diminished.
Nursing Interventions Rationale

Beside analysis of serum glucose is more accurate than

monitoring urine sugar. Urine glucose is not sensitive
enough to detect fluctuations in serum levels and can
be affected by patient’s individual renal threshold or
the presence of urinary retention. Note: Normal levels
Perform fingerstick glucose testing.
for fingerstick glucose testing may vary depending on
how much the patient ate during his last meal. In
general: 80–120 mg/dL (4.4–6.6 mmol/L) before meals
or when waking up; 100–140 mg/dL (5.5–7.7 mmol/L)
at bedtime.

Regular insulin has a rapid onset and thus quickly helps

move glucose into cells. The IV route is the initial route
Administer regular insulin by intermittent or
of choice because absorption from subcutaneous
continuous IV method: IV bolus followed by a
tissues may be erratic. Many believe the continuous
continuous drip via pump of approximately 5–10 U/hr
method is the optimal way to facilitate transition to
so that glucose is reduced by 50 mg/dL/hr.
carbohydrate metabolism and reduce incidence of
hypoglycemia.

Glucose solutions may be added after insulin and fluids

Administer glucose solutions: dextrose and half-normal have brought the blood glucose to approximately 400
saline. mg/dL. As carbohydrate metabolism approaches
normal, care must be taken to avoid hypoglycemia.

Complex carbohydrates (apples, broccoli, peas, dried

beads, carrots, peas, oats) decrease glucose
levels/insulin needs, reduce serum cholesterol levels,
and promote satiation. Food intake is scheduled
Provide diet of approximately 60% carbohydrates, 20%
according to specific insulin characteristics and
proteins, 20% fats in designated number of meals and
individual patient response. Note: A snack at bedtime
snacks.
of complex carbohydrates is especially important (if
insulin is given in divided doses) to prevent
hypoglycemia during sleep and potential Somogyi
response.

May be useful in treating symptoms related to

Administer other medications as
autonomic neuropathies affecting GI tract, thus
indicated: metoclopramide (Reglan); tetracycline.
enhancing oral intake and absorption of nutrients.

Instruct the patient to exercise regularly.

Nursing Interventions Rationale

 Refer the patient to an exercise physiologist,

Specific exercises can be prescribed based on any
physical therapist, or cardiac rehabilitation
physical limitations the diabetic patient may have.
nurse for specific exercise instructions.

 Instruct to do warm-ups and cool-downs for at

Warm-ups and stretching helps prevent muscle injury.
least 30 to 60 minutes.

 Instruct patient in the methods to maintain Dehydration can hasten hypoglycemia, especially in hot
hydration and avoid hypoglycemia during weather. Patients may need to add a snack before
exercise. exercising if they experience hypoglycemia.

Risk for Impaired Skin Integrity

Risk for Impaired Skin Integrity: Altered epidermis and/or dermis.

Risk factors

 Decreased circulation and sensation caused by peripheral neuropathy and arterial obstruction.

Possibly evidenced by

 [Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the
problem has not occurred and nursing interventions are directed at prevention.]

Desired outcomes

 Patient’s skin on legs and feet remains intact while the patient is hospitalized.

 Patient will demonstrate proper foot care.

Nursing Interventions Rationale

These are assessments for neuropathy. Skin on lower

Assess integrity of the skin. Assess knee and deep tendon
extremity pressure points is at great risk for
reflexes and proprioception.
ulceration.
 Use foot cradle on the bed. Use space boots on ulcerated
To prevent pressure on pressure-sensitive points.
heels, elbow protectors, and pressure-relief mattresses.

Wash feet daily with mild soap and warm water. Check
Decreased sensation increases the risk for burns.
water temperature before immersing feet in the water.

Inspect feet daily for erythema or trauma. These are signs that the skin needs preventive care.

Change socks or stockings daily. Encourage the patient to To prevent infection from moisture. White fabric
wear white cotton socks. enables easy visualization of blood or exudates.

Moisturizers soften and lubricate dry skin, preventing

Use gentle moisturizers on the feet.
skin cracking.

Cut toenails straight across after softening toenails with a This action prevents ingrown toenails, which could
bath. cause infection.

This is a high risk for trauma and may result in

The patient should not walk barefoot.
ulceration and infection.

Various health problems and conditions can create a favorable environment that would encourage the
development of infections. Here are the common factors:

 Inadequate primary defenses (e.g., broken skin integrity, tissue damage).

 Insufficient knowledge to avoid exposure to pathogens.

 Compromised host defenses (e.g., cancer, immunosuppression, AIDS, diabetes mellitus).

 Compromised circulation (e.g., obesity, lymphedema, peripheral vascular disease).

 A site for organism invasion (e.g., surgery, dialysis, invasive lines, intubation, enteral feedings).

 Compromised host defenses (e.g.,radiation therapy, organ transplant, medication therapy)

 Compromised host defenses

 Contact with contagious agents

 Increased vulnerability of infant (e.g., HIV-positive mother, lack of normal flora, lack of maternal
antibodies).

 Lack of immunization

 Multiple sex partners

 Chronic diseases
  Rupture of amniotic membranes

Goals and Outcomes

The patient should report risk factors associated with infection and precautions needed.

 Patient remains free of infection, as evidenced by normal vital signs and absence of signs and
symptoms of infection.

 Early recognition of infection to allow for prompt treatment.

 Patient will demonstrate meticulous hand washing technique.

Nursing Assessment

Assessment is paramount in identifying risk factors for Risk for Infection.

Assessment Rationales

Assess for the presence, existence of,

and history of risk factors (mentioned These represent a break in the body’s normal first line of defense.
above).

An increasing WBC count indicates the body’s efforts to combat

pathogens. Rates are as follows:

 Low: Below 4,500

Monitor white blood cell (WBC) count  Normal: 4,500—11,000

 High: Above 11,000

Very low WBC count may indicate a severe risk for infection. In older
patients, infection may be present without an increased WBC count.

Assess and monitor nutritional status, Patients with poor nutritional status may be anergic or unable to
weight, history of weight loss, and muster a cellular immune response to pathogens making them
serum albumin. susceptible to infection.

For pregnant clients, assess the Prolonged rupture of amniotic membranesbefore delivery puts the
intactness of amniotic membranes. mother and neonate at increased risk for infection.

Investigate the use of medications or

Antineoplastic agents, corticosteroids, and so on, can reduce
treatment modalities that may cause
immunity.
immunosuppression.
 People with incomplete immunizations may not have sufficient
Assess immunization status and history.
acquired active immunity.

Monitor the following signs of actual infection:

Redness, swelling, increased pain,

purulent discharge from incisions, These are the classic signs of infection. Any suspicious drainage should
injury, and exit sites of tubes (IV be cultured; antibiotic therapy is determined by pathogens identified.
tubings), drains, or catheters.

Temperature of up to 38º C (100.4º F) 48 hours post-op is usually

related to surgical stress after 48 hours, temperature of greater than
Elevated temperature.
37.7º (99.8º F) may indicate infection; very high temperature
accompanied by sweating and chills may indicate septicemia.

Color of respiratory secretions. Yellow or yellow-green sputum is indicative of respiratory infection.

Cloudy, turbid, foul-smelling urine with visible sediment is indicative of

Appearance of urine.
urinary tract or bladder infection.

Nursing Interventions

The following therapeutic nursing interventions can help reduce the Risk for Infection:

Interventions Rationales

Maintain or teach asepsis for dressing changes Aseptic technique decreases the changes of transmitting or
and wound care, peripheral IV and central spreading pathogens to the patient. Interrupting the
venous management, and catheter care and transmission of infection along the chain of infection is an
handling. effective way to prevent infection.

Wash hands and teach patient and SO to wash Friction and running water effectively remove
hands before contact with patients and between microorganisms from hands. Washing between procedures
procedures with the patient. reduces the risk of transmitting pathogens from one area of
Instances when to wash hands: the body to another.

 Before putting on gloves and after taking
them off.
 Before and after touching a patient,
before handling an invasive device (foley
catheter, IV catheter, and so on)
regardless of whether or not gloves are
used.
Wash hands with antiseptic soap and water for at least 15
seconds followed by alcohol-based hand rub. If hands were
not in contact with anyone or anything in the room, use an
alcohol-based hand rub and rub until dry.
Plain soap is good at reducing bacterial counts but
antimicrobial soap is better, and alcohol-based hand rubs are
the best.
  After contact with body fluids or
excretions, mucous membranes,
nonintact skin, or wound dressings.

 If moving from contaminated body site

to another site during the care of the
same individual.

 After contact with inanimate surfaces

and objects in the immediate vicinity of
the patient.

 After removing sterile or nonsterile

gloves.

 Before handling medications or

preparing food.

Encourage intake of protein-rich and calorie-rich

Helps support the immune system responsiveness.
foods.

Fluids promote diluted urine and frequent emptying

Encourage fluid intake of 2,000 to 3,000 mL of
of bladder – reducing the stasis of urine, in turn, reduces risk
water per day, unless contraindicated.
for bladderinfection or urinary tract infection.

Helps reduce stasis of secretions in the lungs and the

Encourage coughing and deep breathing
bronchial tree. When stasis occurs, pathogens can cause
exercises; frequent position changes.
upper respiratory tract infections and pneumonia.

Recommend the use of soft-bristled

These may compromise the integrity of the mucous
toothbrushes and stool softeners to protect
membranes and provide a port of entry for pathogens.
mucous membranes.

Limit visitors. Restricting visitation reduces the transmission of pathogens.

Provide surgical mask to visitors who are

coughing and provide an explanation why.
Instruct:

 Cover mouth and nose during coughing Educating visitors on the importance of preventing droplet
or sneezing. transmission from themselves to others can help reduce the
risk of infection.
 Use tissues to contain respiratory
secretions with an immediate disposal to
a no-touch receptacle; wash hands with
soap and water afterward.
Place the patient in protective isolation if the Protective isolation is set when WBC counts indicate
patient is at very high risk. neutropenia (less than 500 mm3).

Initiate specific precautions for suspected agents; follow infection prevention according to institution or CDC
protocol.

Meningitis Droplet, airborne precautions

Rubella Airborne precautions

MRSA Contact, droplet precautions

Tuberculosis Airborne precautions

Wear personal protective equipment (PPE):

Wear gloves when providing direct care; wash hands with

Gloves
soap and water after properly disposing of gloves.

Use masks, goggles, or face shields to protect the mucous

membrane of your eyes, mouth, and nose during procedures
Masks and direct-care activities (e.g., suctioning oral secretions) that
may generate splashes or sprays of blood, body fluids,
secretions, and excretions.

Wear a gown for direct contact with uncontained secretions

or excretions. Remove gown and perform hand
Gowns
hygienebefore leaving the patient’s room or cubicle. Do not
reuse gowns even with the same individual.

Teach the patient and/or SO to wash hands

Patients and SO can spread infection from one part of the
often, especially after toileting, before meals,
body to another – handwashing reduces these risks.
and before and after administering self-care.

Teach the patient the importance of avoiding Other people can spread infections or colds to a susceptible
contact with individuals who have infections or patient through direct contact, contaminated objects, or
colds. through air currents.

Demonstrate and allow return demonstration of

all high-risk procedures that the patient and/or
Patient and SO need opportunities to master new skills to
SO will do after discharge, such as dressing
reduce risk for infection.
changes, peripheral or central IV site care, and
so on.
 Teach the patient, family, and caregivers, the
Knowledge about isolation can help patients and family
purpose and proper technique for maintaining
members cooperate with specific precautions.
isolation

Antibiotics work best when a constant blood level is

If infection occurs, teach the patient to
maintained which is done when medications are taken as
take antibiotics as prescribed. Instruct patient to
prescribed. Not completing the prescribed antibioticregimen
take the full course of antibioticseven if
can lead to drug resistance in the pathogen and reactivation
symptoms improve or disappear.
of symptoms.

Related Factors

Here are some factors that may be related to Impaired Tissue Integrity:

 Altered circulation

 Chemical irritants

 Fluid imbalances

 Infection

 Nutritional deficits or extremes

 Radiation

 Surgery

 Temperature extremes

 Trauma

 Weight loss

Defining Characteristics

Impaired Tissue Integrity is characterized by the following signs and symptoms:

 Affected area hot, tender to touch

 Damaged or destroyed tissue (e.g., cornea, mucous membranes, integumentary, subcutaneous)

 Local pain

 Protectiveness toward site

  Skin and tissue color changes (red, purplish, black)

 Swelling around initial injury

Goals and Outcomes

The following are the common goals and expected outcomes for Impaired Tissue Integrity.

 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.

Nursing Assessment

Assessment is required in order to recognize possible problems that may have lead to Impaired Tissue
Integrity as well as identify any episode that may transpire during nursing care.

Assessment Rationales

Determine etiology (e.g., acute or

chronic wound, burn, Prior assessment of wound etiology is critical for proper identification of
dermatological lesion, pressure nursing interventions.
ulcer, leg ulcer).

Assess site of impaired tissue Redness, swelling, pain, burning, and itching are indication of inflammation
integrity and its condition. and the body’s immune system response to localized tissue trauma.

Assess characteristics of wound,
including color, size (length, width,
depth), drainage, and odor.
These findings will give information on extent of injury. Pale tissue color is
a sign of decreased oxygenation. Odor may be a result of presence of
infection on the site; it may also be coming from a necrotic tissue. Serous
exudate from a wound is a normal part of inflammation and must be
differentiated from pus or purulent discharge, which is present in infection.

Assess changes in body

Fever is a systemic manifestation of inflammation and may indicate the
temperature, specifically increased
presence of infection.
in body temperature.

Assess the patient’s level of Pain is part of the normal inflammatory process. The extent and depth of
distress. injury may affect pain sensations.
 Know signs of itching and The patient who scratches the skin in attempts to alleviate extreme itching
scratching. may open skin lesion and increase risk for infection.

Assess patient’s nutritional status;

refer for a nutritional consultation Inadequate nutritional intake places the patient at risk for skin breakdown
and/or institute dietary and compromises healing.
supplements.

Classify pressure ulcers in the Wound assessment is more reliable when classified in such manner
following manner: according to the National Pressure Ulcer Advisory Panel.

Full-thickness skin loss involving damage to or necrosis of subcutaneous

tissue that may extend down to but not through underlying
 Stage III
fascia; ulcer appears as a deep crater with or without undermining of
adjacent tissue

Full-thickness skin loss with extensive destruction; tissue necrosis; or

 Stage IV damage to muscle, bone, or supporting structures (e.g., tendons, joint
capsules)

Pay special attention to all high-risk

areas such as bony prominences, Systematic inspection can identify impending problems early.
skin folds, sacrum, and heels.

Identify a plan for debridement if

necrotic tissue (eschar or slough) is
Healing does not transpire in the appearance of necrotic tissue.
present and if compatible with
overall patient management goals.

Nursing Interventions

The following are the therapeutic nursing interventions for Impaired Tissue Integrity:

Interventions Rationales

Monitor site of impaired tissue integrity at

least once daily for color changes, redness,
Systematic inspection can identify impending problems early.
swelling, warmth, pain, or other signs of
infection.

Monitor status of skin around wound. Monitor Individualize plan is necessary according to patient’s skin
patient’s skin care practices, noting type of condition, needs, and preferences.
soap or other cleansing agents used,
temperature of water, and frequency of skin
cleansing.
Provide tissue care as needed.
Keep a sterile dressing technique during
wound care.
Premedicate for dressing changes as
necessary.
Wet thoroughly the dressings with
sterile normal saline solution before removal.
Monitor patient’s continence status and
minimize exposure of skin impairment site and
other areas to moisture from incontinence,
perspiration, or wound drainage.
If patient is incontinent, implement
an incontinence management plan.
Administer antibiotics as ordered.
Tell patient to avoid rubbing and scratching.
Provide gloves or clip the nails if necessary.
Encourage a diet that meets nutritional needs.
Monitor for proper placement of tubes,
catheters, and other devices. Assess skin and
tissue affected by the tape that secures these
devices.
Each type of wound is best treated based on its etiology. Skin
wounds may be covered with wet or dry dressings, topical
creams or lubricants, hydrocolloid dressings (e.g., DuoDerm) or
vapor-permeable membrane dressings such as Tegaderm. An
eye patch or hard, plastic shield for corneal injury. The dressing
replaces the protective function of the injured tissue during the
healing process.
This technique reduces the risk for infection.
Manipulation of profound or extensive cuts or injuries may be
painful.
Saturating dreesings will ease the removal by loosening
adherents and decreasing pain, especially with burns.
This is to prevent exposure to chemicals in urine and stool that
can strip or erode the skin.
This is to prevent exposure to chemicals in urine and stool that
can strip or erode the skin.
Wound infections may be managed well and more efficiently
with topical agents, although intravenous antibiotics may be
indicated.
Rubbing and scratching can cause further injury and delay
healing.
A high-protein, high-calorie diet may be needed to promote
healing.
Mechanical damage to skin and tissues as a result of pressure,
friction, or shear is often associated with external devices.
Check every 2 hours for proper placement of
Mechanical damage to skin and tissues (pressure, friction, or
foot boards, restraints, traction, casts, or other
shear) is often associated with external devices.
devices, and assess skin and tissue integrity.

For patients with limited mobility, use a risk

This is to identify patients at risk for immobility-related skin
assessment tool to systematically assess
breakdown.
immobility-related risk factors.

Do not position patient on site of impaired

tissue integrity. If ordered, turn and position This is to avoid adverse effects of external mechanical forces
patient at least every 2 hours, and carefully (pressure, friction, and shear).
transfer patient.

Maintain the head of the bed at the lowest

To reduce shear and friction.
degree of elevation possible.

Educate patient about proper nutrition,

The patient needs proper knowledge on his or her condition to
hydration, and methods to maintain tissue
prevent further tissue injury.
integrity.

Teach skin and wound assessment and ways to

Early assessment and intervention help prevent the
monitor for signs and symptoms of infection,
development of serious problems.
complications, and healing.

Instruct patient, significant others, and family

in proper care of the wound including hand Accurate information increases the patient’s ability to manage
washing, wound cleansing, dressing changes, therapy independently and reduce risk for infection.
and application of topical medications).

Encourage use of pillows, foam wedges, and

To prevent pressure injury.
pressure-reducing devices.

Educate patient the need to notify physician or

This is to prevent further complications.
nurse.
Infection control measures in healthcare settings

 The first line of defence against infection is the skin. Any wound due to accidental or deliberate
trauma that causes a break in the surface of the skin, increases the risk of infection

 The use of aseptic or clean techniques can prevent the transmission of bacteria to and from the
wound. This includes the use of sterile equipment,

Antiseptic - cleansing agents and protective clothing (Parker, 2000)

Infection control measures should include:

Hand hygiene
Clean preparation area
Aseptic non-touch technique (ANTT)

When undertaking dressing changes, a non-touch technique should be used that aims to avoid
introducing micro-organisms to a wound and prevent cross infection. This may be either:

 Aseptic (where only sterile objects or fluid come into contact with the wound - mainly used for
wounds healing by primary intention or entry/exit site wounds)

 Clean (where non-sterile gloves and tap water are used; mainly used for certain chronic wounds
and traumatic wounds healing by secondary intention)

• A wound is a disruption of the normal structure and function of the skin and underlying soft
tissue.

• Acute wounds in normal, healthy individuals heal through an orderly sequence of physiological
events that include hemostasis, inflammation, epithelialization, fibroplasia, and maturation.

• When this process is altered, a chronic wound may develop and is more likely to occur in
patients with underlying disorders such as peripheral artery disease, diabetes, venous insufficiency,
nutritional deficiencies, and other disease states.

Wound mechanism

Wounds are generally classified as acute or chronic.

Chronic wounds are generally associated with physiological impairments that slow or prevent
wound healing.

Wounds may be caused by a variety of mechanisms including acute injury to the skin (abrasion,
puncture, crush), surgery and other etiologies that cause initially intact skin to break down (eg.,
ischemia, pressure).
Phases of wound healing

• Wound healing occurs as a cellular response to tissue injury and involves activation of
keratinocytes, fibroblasts, endothelial cells, macrophages, and platelets.

• The process involves organized cell migration and recruitment of endothelial cells for
angiogenesis.

• Many growth factors and cytokines released by these cell types coordinate and maintain wound
healing.

• Acute wounds transition through the stages of wound healing as linear pathway, with clear
start- and endpoints.

• Chronic wounds are arrested in one of these stages, usually the inflammatory stage, and cannot
progress further.

PATHOPHYSIOLOGY

Wound healing is a continuum of complex interrelated biologic processes at the molecular level. For
descriptive purposes, healing may be divided into the following three phases:

• Inflammatory phase

• Proliferative phase

• Maturation phase

Inflammatory phase

The inflammatory phase commences as soon as tissue integrity is disrupted by injury; this begins the
coagulation cascade to limit bleeding. Platelets are the first of the cellular components that aggregate to
the wound, and, as a result of their degranulation (platelet reaction), they release several cytokines (or
paracrine growth factors). These cytokines include platelet-derived growth factor (PDGF), insulinlike
growth factor-1 (IGF-1), epidermal growth factor (EGF), and fibroblast growth factor (FGF).

Serotonin is also released, which, together with histamine (released by mast cells), induces a reversible
opening of the junctions between the endothelial cells, allowing the passage of neutrophils and
monocytes (which become macrophages) to the site of injury.

This large cellular movement to the injury site is induced by cytokines secreted by the platelets
(chemotaxis) and by further chemotactic cytokines secreted by the macrophages themselves once at the
site of injury. These include transforming growth factor alpha (TGF-α) and transforming growth factor
beta (TGF-β).

Consequently, an inflammatory exudate that contains red blood cells, neutrophils, macrophages, and
plasma proteins, including coagulation cascade proteins and fibrin strands, fills the wound in a matter of
hours. Macrophages not only scavenge but they also are central to the wound healing process because
of their cytokine secretion.

Proliferative phase

The proliferative phase begins as the cells that migrate to the site of injury, such as fibroblasts, epithelial
cells, and vascular endothelial cells, start to proliferate and the cellularity of the wound increases. The
cytokines involved in this phase include FGFs, particularly FGF-2 (previously known as basic FGF), which
stimulates angiogenesis and epithelial cell and fibroblast proliferation.

The marginal basal cells at the edge of the wound migrate across the wound, and, within 48 hours, the
entire wound is epithelialized. In the depth of the wound, the number of inflammatory cells decreases
with the increase in stromal cells, such as fibroblasts and endothelial cells, which, in turn, continue to
secrete cytokines. Cellular proliferation continues with the formation of extracellular matrix proteins,
including collagen and new capillaries (angiogenesis). This process is variable in length and may last
several weeks.

Maturation phase

In the maturation phase, the dominant feature is collagen. The dense bundle of fibers, characteristic of
collagen, is the predominant constituent of the scar. Wound contraction occurs to some degree in
primary closed wounds but is a pronounced feature in wounds left to close by secondary intention. The
cells responsible for wound contraction are called myofibroblasts, which resemble fibroblasts but have
cytoplasmic actin filaments responsible for contraction.

The wound continuously undergoes remodeling to try to achieve a state similar to that prior to injury.
The wound has 70-80% of its original tensile strength at 3-4 months after operation.