Impaired Tissue Integrity Nursing Diagnosis and Care Plan

Impaired tissue integrity is one of the most common nursing diagnoses encountered in clinical practice. It describes a disruption in the normal structure and functioning of the skin, mucous membranes, or subcutaneous tissue. Because the skin acts as the body’s first line of defense, damage to this protective barrier increases the risk of infection, fluid loss, and delayed healing.

For nurses, recognizing impaired tissue integrity early and implementing evidence-based interventions is critical. From pressure ulcers and diabetic wounds to burns and surgical incisions, impaired tissue integrity can arise from multiple causes and affect patients across all age groups. A comprehensive care plan ensures that patients receive interventions tailored to promote healing, prevent complications, and restore skin integrity.

This guide provides a detailed overview of the nursing diagnosis of impaired tissue integrity, its causes, risk factors, assessment, nursing interventions, and care plans.

What Is Impaired Tissue Integrity?

Impaired tissue integrity is defined by NANDA-I (North American Nursing Diagnosis Association International) as:

“Damage to the mucous membrane, corneal, integumentary, or subcutaneous tissues.”

It may involve:

• Superficial damage (abrasions, rashes, blisters)

• Partial-thickness wounds (ulcers, burns)

• Full-thickness wounds (deep surgical wounds, pressure ulcers, traumatic injuries)

The severity of tissue impairment can range from minor irritation to extensive damage requiring surgical repair.

Nursing Diagnosis: Impaired Tissue Integrity

The nursing diagnosis generally includes:

• Problem Statement: Impaired tissue integrity related to physical, biological, or chemical factors.

• Related Factors: Immobility, infection, poor circulation, nutritional deficiencies, etc.

• Defining Characteristics: Observable symptoms such as redness, open wounds, or drainage.

Defining Characteristics of Impaired Tissue Integrity

When assessing a patient, nurses may identify the following signs and symptoms:

• Disruption of skin layers (ulcers, abrasions, cuts, incisions)

• Redness, swelling, inflammation

• Drainage or pus, possibly with foul odor

• Necrotic (dead) tissue or eschar formation

• Delayed wound healing

• Pain, tenderness, or discomfort in the affected area

• Skin discoloration or loss of sensation

• Dry, fragile, or peeling skin

Related Factors and Causes

Impaired tissue integrity can result from a wide range of contributing factors. Common causes include:

1. Physical Injury

• Accidental cuts, abrasions, punctures

• Burns (thermal, electrical, chemical, or radiation)

• Pressure ulcers from prolonged immobility

• Surgical wounds

2. Medical Conditions

• Diabetes mellitus – impairs wound healing and increases infection risk

• Peripheral vascular disease – reduces circulation, leading to ischemia

• Autoimmune disorders – such as lupus or scleroderma

3. Nutritional Deficiencies

• Lack of protein delays collagen formation

• Deficiencies in vitamins A, C, and E slow wound healing

• Zinc deficiency impairs cell repair

4. Infections

• Bacterial or fungal infections compromise skin integrity

• Chronic infections increase the likelihood of tissue necrosis

5. Immobility

• Bedridden patients are at high risk for pressure ulcers

• Patients in casts or traction may also experience impaired skin integrity

6. Lifestyle and Environmental Factors

• Poor hygiene

• Smoking (reduces blood flow and oxygen delivery to tissues)

• Prolonged moisture exposure (incontinence, sweating)

Risk Factors

Certain populations are at greater risk:

• Older adults (due to thinning skin and reduced elasticity)

• Patients with chronic illnesses (diabetes, vascular disease, cancer)

• Malnourished individuals

• Bedridden or wheelchair-bound patients

• Patients undergoing long-term corticosteroid therapy (slows healing)

Nursing Assessment for Impaired Tissue Integrity

A thorough assessment helps determine the extent of tissue damage and guides the care plan.

Key Assessment Steps

Inspect the Affected Area

Note wound size, depth, color, location, and drainage.

Look for signs of infection (redness, warmth, swelling).

Palpate for Abnormalities

Assess temperature, tenderness, or induration around the wound.

Assess Systemic Indicators

Monitor for fever, increased heart rate, or leukocytosis (possible systemic infection).

Evaluate Contributing Factors

Assess immobility, incontinence, or poor nutrition.

Review Patient’s Medical History

Diabetes, vascular disease, recent surgery, or immune suppression.

Use Standardized Tools

Braden Scale for predicting pressure sore risk.

Bates-Jensen Wound Assessment Tool (BWAT) for wound severity.

Nursing Care Plan for Impaired Tissue Integrity

A structured nursing care plan should address prevention, healing, and education.

1. Nursing Goals

• Promote wound healing

• Prevent infection

• Reduce pain and discomfort

• Prevent further tissue damage

• Educate patient and family on wound care

2. Nursing Interventions

Wound Care

• Cleanse wound with sterile saline or antiseptic solution

• Remove necrotic tissue via debridement (surgical, enzymatic, or autolytic)

• Apply appropriate dressings:

  • Hydrocolloid or hydrogel (for moist healing)

  • Foam or alginate (for heavy exudate)

  • Transparent films (for superficial wounds)

Pressure Relief

• Reposition bedridden patients every 2 hours

• Use pressure-relieving devices (special mattresses, cushions)

Infection Control

• Practice strict aseptic technique during wound care

• Monitor for signs of infection (odor, pus, systemic symptoms)

• Administer prescribed antibiotics promptly

Pain Management

• Provide analgesics before wound care procedures

• Offer non-pharmacologic methods (relaxation, distraction, guided imagery)

Nutrition Support

• Encourage high-protein, vitamin-rich diet

• Include vitamin A, C, and zinc for healing

• Ensure adequate hydration

Patient Education

• Teach patients proper wound cleansing and dressing techniques

• Emphasize personal hygiene

• Promote smoking cessation for better circulation

• Encourage mobility to improve circulation and prevent pressure sores

Expected Outcomes

With proper care, expected outcomes include:

• Reduction in wound size and depth

• Formation of granulation tissue (indicating healing)

• No new wounds or tissue breakdown

• Absence of infection signs

• Patient reports reduced pain

• Patient demonstrates self-care knowledge

Common Conditions Leading to Impaired Tissue Integrity

1. Pressure Ulcers

• Occur in immobile patients

• Caused by unrelieved pressure on bony prominences

• Can progress from redness (stage I) to full-thickness skin and tissue loss (stage IV)

2. Diabetic Ulcers

• Result from neuropathy and poor circulation

• Often occur on the feet

• Require careful management to prevent amputation

3. Surgical Wounds

• Postoperative wounds risk infection and dehiscence

• Require sterile dressing changes and monitoring

4. Burns

• Can be thermal, electrical, or chemical

• Severity depends on depth and body surface area affected

5. Traumatic Injuries

• Cuts, abrasions, or punctures

• Require cleaning, suturing, and infection prevention

6. Infections

• Conditions like cellulitis or fungal infections damage skin tissue

• Require antimicrobial treatment

Complications of Impaired Tissue Integrity

If untreated or poorly managed, complications may include:

• Infections (localized or systemic sepsis)

• Delayed wound healing (chronic wounds)

• Scarring and keloids

• Pain and discomfort

• Loss of function (especially in severe burns or pressure ulcers)

Prevention of Impaired Tissue Integrity

Nurses can implement preventive measures to protect at-risk patients:

• Regular Skin Assessments: Daily inspection, especially in immobile patients

• Pressure Ulcer Prevention: Frequent repositioning, padding, use of specialty mattresses

• Encourage Mobility: Walking, physical therapy, and repositioning

• Maintain Hygiene: Keep skin clean and dry

• Optimize Nutrition: Adequate protein and vitamins to support wound repair

• Moisture Control: Manage incontinence with barrier creams

Nursing Care Plan NCLEX-Style

Nursing Diagnosis: Impaired tissue integrity related to pressure and immobility as evidenced by stage II pressure ulcer on sacrum.

Goals/Expected Outcomes:

• Wound will show signs of healing within 2 weeks.

• Patient will verbalize pain relief strategies.

• No new areas of skin breakdown will occur.

Interventions:

1. Reposition patient every 2 hours.

2. Cleanse wound with normal saline and apply hydrocolloid dressing daily.

3. Provide air mattress to reduce pressure.

4. Monitor for infection (odor, pus, fever).

5. Provide high-protein diet with vitamin C supplementation.

6. Educate patient and family about skin inspection and care.

Evaluation:

• Wound size reduced by 50% in 2 weeks.

• Patient reports decreased pain.

• No new pressure sores observed.

Final Thoughts

The nursing diagnosis of impaired tissue integrity is essential for guiding patient care when the skin or underlying tissue is damaged. Whether the cause is pressure, trauma, surgery, or chronic illness, effective nursing care requires thorough assessment, timely interventions, and patient education.

By addressing nutrition, infection prevention, wound care, and lifestyle modifications, nurses can significantly improve healing outcomes and reduce complications. Prevention remains the best strategy, especially in high-risk patients, making routine skin assessments and mobility support vital components of care.

Understanding impaired tissue integrity and developing comprehensive nursing care plans equips nurses to deliver evidence-based, compassionate, and effective care that promotes recovery and enhances quality of life.