IMPAIRED TISSUE INTEGRITY

Cues/Ne Nursin Rationale Goals and Interventi Rationale Evaluation

eds g Objectives ons
Diagno
sis
Subjecti Impair There is a After 2 days of -promote -to After 2
ve: ed damaged nursing optimum facilitate days of
tissue integument intervention, the nutrition healing. nursing
integrit ary tissue/ client’s wound with high interventio
Objectiv y wound will have visible quality n,
e: related present at improvement/he protein Goal
- to burn the client’s aling. and -to limit partially
scatterre injury face, neck sufficient metabolic met,
d and wrists. calories. demands,
The
damage maximize
client’s
d skin energy
- wound
tissue on available
encourage for healing, showed
the face,
adequate visible
neck and and meet
periods of comfort improvem
wrists
rest and needs. ent, the
-moist sleep wound
on the appeared
nasal to by dry.
-reduces
area risk for
cross-
contaminat
ion.

-practice
aseptic
technique
for
cleansing
lesions.