Nurse's Pocket Guide

Record size (depth, width), color, location, temperature,
texture of wounds/lesions.
Determine degree/depth of injury/damage to integumentary
system (involves epidermis, dermis, and/or underlying tissues),
extent of tunneling/undermining, if present. Note:
Full extent of lesions of mucous membranes or subcutaneous
tissue may not be discernible.
Identify stage of ulcers/wound (I-IV) and classify burns using
appropriate measuring tool.
Document with drawings and/or photograph wound/
lesion(s)/burns, as appropriate.
Observe for other distinguishing characteristics of surrounding
tissue (e.g., exudate; granulation; cyanosis/pallor; tight,
shiny skin).
Describe wound drainage (e.g., amount, color/odor).
• Assist with diagnostic procedures (e.g., x-rays, imaging scans,
biopsies, debridement). May be necessary to determine
extent of impairment.
• Determine psychological effects of condition on client/SO(s).
Can be devastating for client’s body/self-image and esteem,
especially if condition is severe/disfiguring or chronic, as
well as costly and burdensome for SO(s)/caregiver.
NURSING PRIORITY NO. 3.To assist client to correct/minimize
impairment and to promote healing:
• Modify/eliminate factors contributing to condition, if possible.
Assist with treatment of underlying condition(s), as appropriate.
• Inspect lesions/wounds daily, or as appropriate, for changes
(e.g., signs of infection/complications or healing). Promotes
timely intervention/revision of plan of care.
• Promote optimum nutrition with high-quality protein and
sufficient calories, vitamins, and mineral supplements to
facilitate healing.
• Encourage adequate periods of rest and sleep to limit metabolic
demands, maximize energy available for healing, and
meet comfort needs.
• Limit/avoid use of caffeine/alcohol and medications affecting
REM sleep.
• Provide/assist with oral care (e.g., teaching oral/dental
hygiene, avoiding extremes of hot or cold, changing position
of ET/NG tubes, lubricating lips, etc.) to prevent damage to
mucous membranes.
• Promote early mobility. Assist with/encourage position
changes, active/passive and assistive exercises to promote
circulation and prevent excessive tissue pressure.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 703
impaired TISSUE INTEGRITY