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Care plan for risk for impaired skin integrity?
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Care plan for risk for impaired skin integrity?
To prevent skin breakdown, the nurse should: a) institute (ROM) exercise every 4 hours. Assess the characteristics of the wound. Interventions. Jun 11, 2023 · The goal is to address the underlying causes of impaired skin integrity and prevent future episodes. Prolonged exposure to urine can lead to skin irritation and breakdown, especially among older adults or immobile clients See also: Wound Care and Skin/Tissue Integrity Nursing Care Plan and Management Meatal care reduces the risk of infection. Use pressure relieving devises as directed. Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation. Roc Skin Care Products Hand Lotion is a must-have for a. Nursing diagnosis of Impaired Skin Integrity can be used to identify and assess the risk of skin damage. Oct 11, 2021 · When the skin is compromised due to cuts, abrasions, ulcers, incisions, and wounds, it allows bacteria to enter, causing infections. Risk Factors for Impaired Skin Integrity. Desired outcomes must be achieved for the effectiveness of the treatment. Understanding the patient profile helps determine the right treatment plan. Specific wound assessment tools may assist nurses to structure an assessment, but wider holistic factors also need to be considered. Risk for Impaired Skin Integrity related to frequent stool contact. Assess skin over bony prominences where the risk of skin breakdown is greatest 3. The mother's body continues to go through changes as it returns to a prepregnancy baseline. Even if you don’t care about the wrinkles caused by dry skin, you c. Desired Outcome: The patient will maintain skin integrity by expediently improving wound condition, preventing infection, and reporting any observable skin changes. Incorporating best practices in identifying and treating malnutrition in a timely manner improves clinical outcomes malnutrition diagnosis, and nutrition care plan. Nursing care plan for impaired skin integrity (including diagnosis): Impaired Skin Integrity, Risk for Skin Breakdown, Altered Skin Integrity, and Risk for Pressure Ulcers. Desired Outcome: The patient will re-establish healthy skin integrity by following treatment regimen for cellulitis. Because the damage is at the skin level, it is not impaired tissue integrity (option 3) since that would involve deeper tissues. Implementation, A patient's plan of care includes the goal of increasing mobility this shift. When working with patients at risk for or suffering from impaired skin integrity, creating a comprehensive nursing care plan is crucial. Disturbed sensory perception related to impaired nerve stimulation. goal: Skip to document 3 Dx Care Plan Risk for Impaired Skin Integrity, Risk for Falls, Risk for Infection. Which is the appropriate intervention of the nurse? a. Expected outcomes include the absence of new or worsening skin breakdown, implementation of preventive measures, and patient and caregiver education on proper skin care and prevention strategies. Assess patient skin, prevent breakdown and make a plan for skin health. What are some risk factors for impaired skin integrity? Risk factors for impaired skin integrity can include limited mobility, iron deficiency anemia, obesity, smoking, use of systemic medications, excessive sun exposure, exposure to allergens or irritants, and more. Evaluate what causes the tissue damage. Understanding Impaired Skin Integrity: Definition, Causes, and Risk Factors. Compromised skin through internal or external causes increases the risk of pressure ulcer injury. Definition and Types of Impaired Skin Integrity. Assess patient skin, prevent breakdown and make a plan for skin health. The patient will be free of wounds on the skin by 10/24/2021 as evidenced by: Patients open wounds on the right ischium and. It can also be used to provide direction for nursing interventions and to establish eligibility for clinical care plans, such as wound care procedures or lifestyle modification recommendations. Assist with position changing as directed. Related to: Poor nutritional status Impaired circulation. The label suggests the outcomes. This template is handy in various clinical scenarios, providing a structured approach to address and manage issues related to impaired skin integrity. Nursing care plan for impaired skin integrity (including diagnosis): Impaired Skin Integrity, Risk for Skin Breakdown, Altered Skin Integrity, and Risk for Pressure Ulcers. Nursing care plan for risk of impaired skin integrity is required when patients are at risk of or have suffered skin damage due to medical treatment, extended hospital stay, medications, or lifestyle. Risk for Impaired Skin Integrity Interventions Keep the skin clean and dry. Elizabeth Thompson, a 68-year-old patient with a Stage III pressure ulcer on the sacrum. Nursing diagnosis of Impaired Skin Integrity can be used to identify and assess the risk of skin damage. Get to know the nursing assessment, interventions, goals, and nursing diagnosis for impairment in tissue integrity. A nurse is completing a care plan. Nursing diagnosis of Impaired Skin Integrity can be used to identify and assess the risk of skin damage. Causes, and Risk Factors. Risk assessment per protocols. Skin will remain intact and without redness during hospital stay Rationale: The human response/label is what needs to change (Risk for impaired skin integrity). Shearing or friction Immobility 10 INTEGUMENTARY INTRODUCTION. Learning Objectives. In today’s digital age, technology has become an integral part of the modern classroom. Risk for Impaired Skin Integrity Care Plan The skin is a delicate yet important organ. Identify factors related to alterations in the integumentary system across the life span. 209 Varicose veins of unspecified. Causes of Impaired Skin Integrity. Examine the skin's general state. Impaired skin integrity d. com +(44) 731-183-9056. When working with patients at risk for or suffering from impaired skin integrity, creating a comprehensive nursing care plan is crucial. It can also be used to provide direction for nursing interventions and to establish eligibility for clinical care plans, such as wound care procedures or lifestyle modification recommendations. Nursing care plan for risk of impaired skin integrity is required when patients are at risk of or have suffered skin damage due to medical treatment, extended hospital stay, medications, or lifestyle. Atopic dermatitis is the most common type of eczema. With surgery incisions, this patient may have a greater risk for compromised skin integrity. Nursing Diagnosis: Impaired Skin Integrity related to skin breakdown secondary to pressure ulcer as indicated by a pressure sore on the sacrum, a few days of sore discharge, pain, and soreness. Diagnostic focus: Tissue integrity. The patient is at risk for epidermis and dermis injury due to numbness and impaired sensations. The RN will help the. Chickenpox, also known as varicella infection, is a common childhood illness caused by an infection from the varicella zoster virus. Causes of Impaired Skin Integrity. Promoting skin integrity and skin health is a fundamental part of your daily efforts to prevent skin breakdown. Skin and Wound Assessment. Avoid rubbing or brisk drying. 2. Assess general condition of skin. These can include: Aging Prolonged pressure Sep 12, 2022 · The assessment and management of impaired skin integrity as part of wound care is a common nursing task. Identify the patients at risk for impaired skin integrity. Neuropathy (impaired sensation) Moisture/Incontinence. Pflegepersonal Care Layout for Impaired Skin Inferior Pflegen Care Plan 1. The RN will help the. Use at least two scholarly sources to support your care plan. Key points Maintenance of skin integrity during the elder years is a challenge for most people. One such technological innovation that has gained popularity in classrooms is the smart bo. cottage for sale in scotland Applying talcum powder to the irradiated areas daily after bathing C. Neuropathy (impaired sensation) Moisture/Incontinence. Signs and Symptoms of Impaired Skin Integrity. Elizabeth Thompson, a 68-year-old patient with a Stage III pressure ulcer on the sacrum. Keep skin clean, dry and moisturize skin as directed. Imbalanced nutrition: Less than body requirements related to thyroid hormone excess The nurse adds Risk for impaired skin integrity to the plan of care. Jun 11, 2023 · The goal is to address the underlying causes of impaired skin integrity and prevent future episodes. These nursing diagnosis for sinusitis provide a basis for developing a comprehensive care plan that addresses the specific needs of patients with sinusitis. The nurse ensured the nursing assistive personnel changed the patient's position every 2 hours. Understanding Impaired Skin Integrity: Definition, Causes, and Risk Factors. 009 Varicose veins of unspecified LE with ulcer at unspecified site I83. Related to: Poor nutritional status Impaired circulation. Planning and executing a successful event requires careful attention to detail, and one of the most important aspects is the catering. Desire Outcomes: The patient will be able to identify appropriate interventions for the specific condition. With surgery incisions, this patient may have a greater risk for compromised skin integrity. Skin integrity: What it is and how to protect every layer. Keep skin clean, dry and moisturize skin as directed. Founded by a team of passionate and dedicated individuals, The Soap Guy has crea. Specific wound assessment tools may assist nurses to structure an assessment, but wider holistic factors also need to be considered. Risk for suffocation ANS: B Rationale: If endotracheal intubation is necessary, extreme care is taken to avoid flexing or extending the client's neck, which can result in extension of a cervical injury. Loss of skin integrity may result from a variety of factors. Assess general condition of skin. Risk for infection: Preventing potential postoperative infections is of utmost importance to ensure optimal wound healing, reduce the risk of complications, and safeguard the client's overall health. Which intervention should the nurse expect to include as. 2500 watt power acoustik amp Understanding Impaired Skin Integrity: Definition, Causes, and Risk Factors. Skin integrity: What it is and how to protect every layer. Promoting skin integrity and skin health is a fundamental part of your daily efforts to prevent skin breakdown. 209 Varicose veins of unspecified. It involves various assessment steps, diagnosis, outcomes, interventions and rationales as described above. evidenced by abdominal aortic aneurysm repair Subjective. Which nursing diagnosis would be the priority for this client?. Nursing Diagnosis: Risk for Impaired Skin Integrity related to the onset of skin breakdown, secondary to edema, as evidenced by skin appearing to be stretched, presence of tenderness, discomfort, pitting, and swelling at the site of injury. Impaired Skin Integrity Interventions Keep the skin clean and dry. Contents: Cellulitis is an infection of the skin (epidermis and dermis) or underlying soft tissues (hypodermis); it can spread rapidly and be life-threatening. 33,34 These evidence-based outcome statements are valid and reliable. Objectives: The objective was to summarize the. Oct 15, 2022 · The elimination of dead tissue, control of exudate, prevention of bacterial overgrowth, maintenance of adequate fluid balance, cost-efficiency, and manageability for the patient and/or nursing staff are all factors in wound care. The nurse should come up with some effective nursing interventions to reduce the risk of impaired skin integrity. Pressure injuries are localized areas of soft tissue damage that typically occur in older adult populations, people with limited mobility or who are confined to the bed or. Impaired tissue integrity may be a sign of underlying health problems that require nursing care. Risk For Impaired Skin Integrity. It is important that nurses understand how to assess, prevent, treat, and educate patients on impaired skin integrity. The nurse care plan for a patient with AIDS includes the diagnosis of Risk for Impaired Skin Integrity. The skin has many important functions; including protection from harmful substances and microbes, prevention of loss of body water, and temperature control. billy joel msg seating chart Nursing Care Plan for Colostomy 1. Diagnostic Code: 00044. It is important that nurses understand how to assess, prevent, treat, and educate patients on impaired skin integrity. The etiology of compromised tissue can vary widely. It can also be used to provide direction for nursing interventions and to establish eligibility for clinical care plans, such as wound care procedures or lifestyle modification recommendations. Examine the skin's general state. Pressure areas must be treated with white wool or sheepskin and examined with a long-handled metal spatula to detect any signs of redness, heat, or swelling. Risk for impaired skin integrity; Risk for injury; Risk for infection; Risk for electrolyte imbalance; Risk for acute confusion; Sample nursing care plan for acute renal failure. Atopic dermatitis is the most common type of eczema. Assist with position changing as directed. Nursing Diagnosis: Impaired Skin Integrity related to infection of the skin secondary to cellulitis, as evidenced by erythema, warmth and swelling of the affected leg. Utilize skin and wound care products to prevent and manage skin breakdown in patients with non-intact or intact skin 1. Holloway S, Jones V. Expected outcomes include the absence of new or worsening skin breakdown, implementation of preventive measures, and patient and caregiver education on proper skin care and prevention strategies.
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Signs and Symptoms of Impaired Skin Integrity. Signs and Symptoms of Impaired Skin Integrity. Identify the patients at risk for impaired skin integrity. Assess patient skin, prevent breakdown and make a plan for skin health. Taking a family holiday is a great way to create lasting memories and spend quality time together. Main Article: 4 Dermatitis Nursing Care Plans. Nursing Care Plan for Venous Stasis Ulcer 2. With some careful planning and sm. Impaired Skin Integrity Nursing Diagnosis. This template is handy in various clinical scenarios, providing a structured approach to address and manage issues related to impaired skin integrity. These nursing diagnosis for sinusitis provide a basis for developing a comprehensive care plan that addresses the specific needs of patients with sinusitis. Mar 14, 2022 · Following are some examples of how a nursing care plan can be developed for patients who are at-risk for impaired skin integrity: Nursing Plan 1 – Pressure ulcers/Bedsores Apr 8, 2023 · Table of Contents. Other: Interventions Assess skin, noting color, moisture, texture, temperature; note erythema , edema, and tenderness. Nursing Care Planning and Goals. Assessment of the wound etiology will help to properly identify the nursing interventions and the treatment strategies for better outcomes Check for the site of impaired tissue integrity and the condition of the wound. Desired outcomes must be achieved for the effectiveness of the treatment. These can include: Aging Prolonged pressure Sep 12, 2022 · The assessment and management of impaired skin integrity as part of wound care is a common nursing task. Study with Quizlet and memorize flashcards containing terms like Which hypothesis would the nurse select for a patient who experiences increased heart rate and increased oxygen requirements when eating? Fall Activity Intolerance Risk for Deep Vein Thrombosis Risk for Impaired Skin Integrity, Which cue would the nurse rank as priority for a patient who suffered multiple fractures after a motor. This standard will focus on patients at increased risk for impaired skin integrity as well as the following types of integumentary disorders (with ICD-10 codes): L89. what is abex procedure cost It includes an assessment of factors that could impact skin integrity like nutrition, mobility, incontinence, medical history and skin conditions. It can also be used to provide direction for nursing interventions and to establish eligibility for clinical care plans, such as wound care procedures or lifestyle modification recommendations. The patient is at risk for epidermis and dermis injury due to numbness and impaired sensations. #5 safety and security Risk for activity intolerance. Nursing Care Plan Diabetes Impaired Skin Integrity Impaired Skin Integrity related to Diabetes Mellitus Impaired Skin Integrity related to. Study with Quizlet and memorize flashcards containing terms like The nurse is attempting to reduce the risk for impaired skin integrity related to immobility in a toddler. Risk for Infection related to traction pin sites: Traction pins can serve as a portal for infection. Understanding the patient profile helps determine the right treatment plan. Desired Outcome: The patient will maintain skin integrity by expediently improving wound condition, preventing infection, and reporting any observable skin changes. These can include: Aging Prolonged pressure Sep 12, 2022 · The assessment and management of impaired skin integrity as part of wound care is a common nursing task. Definition and Types of Impaired Skin Integrity. Related to: Poor nutritional status Impaired circulation. Prevention of skin and foot disorders at all levels of multidisciplinary care is crucial in dealing with the physical and psychological deterioration that individuals with diabetes face due to these disorders. woodland for sale scotland with planning permission Healthy skin varies from individual to individual, but should have good turgor (an indication of moisture), feel warm and dry to the touch, be free of impairment, and have quick capillary refill (less than 6 seconds). Maintaining skin in a supple and moist condition can help prevent many skin injuries Intrinsic factors, such as altered nutrition, vascular disease issues, and diabetes, can affect skin integrity. February 2024. Related to: Poor nutritional status Impaired circulation. The Braden Q Scale was used to assess patient risk for pressure ulcer. Promoting skin integrity and skin health is a fundamental part of your daily efforts to prevent skin breakdown. Impaired Skin Integrity Nursing Diagnosis. Use pressure relieving devises as directed. A school-age client is experiencing severe itching in both hands that is worse at night. Risk for Impaired Skin Integrity. When working with patients at risk for or suffering from impaired skin integrity, creating a comprehensive nursing care plan is crucial. The nurse evaluates the client after 1 week and finds the skin integrity is not impaired. Causes Prolonged bed rest Edema Writing a clear-effective nursing care plan for impaired tissue integrity can be challenging for most students and even nursed on duty support@assignmenthelptalk. Include two scholarly sources to support information in the care map. Apr 29, 2024 · For this nursing care plan and management guide learn how to provide care for patients with wounds or break in their tissue/ skin integrity. The primary goal of a care plan is to safeguard and improve the patient's skin integrity by providing holistic and individualized. Neuropathy (impaired sensation) Moisture/Incontinence. Nursing diagnosis of Impaired Skin Integrity can be used to identify and assess the risk of skin damage. Immobility, which leads to pressure, shear, and friction, is the factor most likely to put an individual at risk for altered skin integrity. Skin integrity: What it is and how to protect every layer. The nursing diagnosis Impaired Physical Mobility is defined as the limitation in independent, purposeful physical movement of the body Check for skin integrity for signs of redness and tissue ischemia (especially over ears, shoulders, elbows,. Which is an accurate goal that the nurse should include for the new nursing diagnosis? Patient will report altered sensation or pain at risk areas as soon as noted. Oct 21, 2008. ksl traffic cameras Get to know the nursing assessment, interventions, goals, and nursing diagnosis for impairment in tissue integrity The Indiana Pressure Ulcer Initiative is a health care initiative of the Indiana State Department of Health and the University of Indianapolis Center for Aging & Community Version: Oct. Nursing care plan for risk of impaired skin integrity is required when patients are at risk of or have suffered skin damage due to medical treatment, extended hospital stay, medications, or lifestyle. Assess patient skin, prevent breakdown and make a plan for skin health. Physical injury Diagnostic Code: 00047 Nanda label: Risk for impaired skin integrity Diagnostic focus: Skin integrity. Nursing Diagnosis: Impaired Skin Integrity. Assist with position changing as directed. Although an assessment of the perineal skin and response to specific products should govern the skin care plan for an incontinent patient, also consider the following general guidelines: ♦Intact skin and mild to severe urinary incontinence. Nursing Diagnosis: Impaired Skin Integrity. Maintaining skin in a supple and moist condition can help prevent many skin injuries Intrinsic factors, such as altered nutrition, vascular disease issues, and diabetes, can affect skin integrity. February 2024. Signs and Symptoms of Impaired Skin Integrity. To ensure the safety of the client, which nursing diagnosis should the nurse assign to this client and address in the care plan? Risk for Allergy Response related to latex allergy. Fall Risk and Fall Prevention Nursing Care Plan. Develop a SMART client-centered outcome and individualized nursing interventions with rationale (using the template on page 2 of this document) for a client with the following nursing diagnosis on the care plan. Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation. These interventions can be as follows: Assess … Nursing care plan for risk of impaired skin integrity is required when patients are at risk of or have suffered skin damage due to medical treatment, extended hospital stay, … According to the National Pressure Ulcer Advisory Panel (NPUAP), skin integrity is defined as the capability of the skin to resist injury and the extent to which the skin is unbroken … The assessment and management of impaired skin integrity as part of wound care is a common nursing task.
Whether it’s a corporate conference, a birthday party, or a wedding, last-minute event planning requ. Risk for Impaired Skin Integrity: Risk factors: medical equipment such as cast or splint; invasive procedures Risk for Infection: Risk factors: chronic disease, inadequate primary defenses, increased exposure to pathogens Impaired Physical Mobility r/t loss of integrity of the bone structure, stiffness of affected body part a. Understanding the patient profile helps determine the right treatment plan. These can include: Aging Prolonged pressure Sep 12, 2022 · The assessment and management of impaired skin integrity as part of wound care is a common nursing task. Loss of skin integrity may result from a variety of factors. Identify factors related to alterations in the integumentary system across the life span. These factors can be both external and internal. Patient will report altered sensation or pain at risk areas as soon as noted. railway recipe minecraft Jun 11, 2023 · The goal is to address the underlying causes of impaired skin integrity and prevent future episodes. Promoting skin integrity and skin health is a fundamental part of your daily efforts to prevent skin breakdown. - Area is usually over a bony prominence Some hospitals may have the information displayed in digital format, or use pre-made templates. the tissue nutrient delivery and skin integrity. Definition and Types of Impaired Skin Integrity. The client has a high-priority nursing diagnosis for Risk for Impaired Skin Integrity related to the need for several weeks of imposed bed rest. etrailer kayak rack Oliveira JS, Nóbrega MMLd, Silva MAd, Soares MJGO. Impaired skin integrity. The etiology of compromised tissue can vary widely. Neuropathy (impaired sensation) Moisture/Incontinence. Maintaining skin in a supple and moist condition can help prevent many skin injuries Intrinsic factors, such as altered nutrition, vascular disease issues, and diabetes, can affect skin integrity. February 2024. mo liquidation warehouse The nurse chooses to revise the plan of care Risk for Impaired Skin Integrity related to decreased peripheral circulation secondary to diabetes. Shearing or friction Immobility 10 INTEGUMENTARY INTRODUCTION. Learning Objectives. 209 Varicose veins of unspecified. Driving with a chipped windshield can be a hazard, as it compromises the structural integrity of your vehicle and impairs your visibility. not all skin lesions extend into the subcutaneous layer which is the defining reason for using impaired tissue integrity. further skin breakdown.
Expected outcomes include the absence of new or worsening skin breakdown, implementation of preventive measures, and patient and caregiver education on proper skin care and prevention strategies. Assess the characteristics of the wound. Interventions. Identify factors related to alterations in the integumentary system across the life span. Impaired skin integrity (if scalp irritation is present) Suggestions for Use: Assess the client's perception of hair loss and its impact on self-image. Correct response: Risk for Infection related to suppressed bone marrow function Explanation: Because doxorubicin suppresses bone marrow function, the patient is at risk of leukopenia and subsequent infection. Preventive interventions and early management can minimize the severity of the skin reaction. Get to know the nursing assessment, interventions, goals, and nursing diagnosis for impairment in tissue integrity. Your doctor can prescribe medicines for atopic dermatitis — and you can al. The student nurse is developing a care plan for a child who suffered a fractured tibia and will have a cast on his lower leg for approximately 6 weeks. Assist with position changing as directed. It is important that nurses understand how to assess, prevent, treat, and educate patients on impaired skin integrity. Nursing Diagnosis: Impaired Skin Integrity related to skin surface disruption with destruction of skin layers (partial/full-thickness burn) that necessitates grafting secondary to burns as evidenced by absence of viable tissue To prevent cross-contamination and lowers the risk of. Administer appropriate antibiotics perioperatively. Impaired Skin Integrity Nursing Diagnosis. Maintaining skin in a supple and moist condition can help prevent many skin injuries Intrinsic factors, such as altered nutrition, vascular disease issues, and diabetes, can affect skin integrity. February 2024. The following are common nursing care planning goals and expected outcomes for impaired skin integrity: 1. Risk for Imbalanced Fluid Volume related to diarrhea. freaky moods videos Imbalanced Nutrition: less than body requirements related to anorexia and vomiting. The following are the nursing priorities for patients with hemorrhoids: Alleviate pain and discomfort associated with hemorrhoids. One valuable tool that can ass. Promoting skin integrity and skin health is a fundamental part of your daily efforts to prevent skin breakdown. Use pressure relieving devises as directed. This template is handy in various clinical scenarios, providing a structured approach to address and manage issues related to impaired skin integrity. impaired skin integrity The wound was not a clean wound, such as a surgical wound, so risk for infection would be a top priority. With the plethora of skincare products available in the market, it can be overwhelming to determine the bes. It plays vital roles in your body by helping to maintain your vision, skin health and even your immune system’s ability. Neuropathy (impaired sensation) Moisture/Incontinence. Use pressure relieving devises as directed. Risk for impaired skin integrity B Risk for autonomic dysreflexia D. Cite sources in-text and on a reference page using APA format. By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN. Monitor for and prevent complications, such as bile leakage or infection. However, having a consistent and effective beauty routine is essential for maintaining healthy skin an. evidenced by abdominal aortic aneurysm repair Subjective. Assess general condition of skin. online library jw.org If the skin is compromised due to cuts, abrasions… Which skin is one body's outermost defense scheme is keeps pathogens from entering and causing illness. Assess a patient’s skin integrity. Assess the characteristics of the wound. Interventions. Such a plan covers multiple areas, involving diagnosis, goal setting, interventions, and regular evaluation. Healthy skin varies from individual to individual, but should have good turgor (an indication of moisture), feel warm and dry to the touch, be free of impairment, and have quick capillary refill (less than 6 seconds). Apr 29, 2024 · For this nursing care plan and management guide learn how to provide care for patients with wounds or break in their tissue/ skin integrity. Extrinsic factors include falls, accidents, pressure, immobility, and surgical. Evaluate what causes the tissue damage. the tissue nutrient delivery and skin integrity. This standard will focus on patients at increased risk for impaired skin integrity as well as the following types of integumentary disorders (with ICD-10 codes): L89. Nursing Diagnosis: Impaired Tissue Integrity related to gangrene secondary to peripheral vascular disease as evidenced by blisters and lesions on the patient's fingers and toes. These interventions can be as follows: Assess skin integrity: It is important to regularly inspect the patient’s skin to identify any early signs of skin breakdown. "Values should return to normal within five minutes or less" (Ralph. Assess for the etiology of the impaired skin integrity. Get to know the nursing assessment, interventions, goals, and nursing diagnosis for impairment in tissue integrity.