Defining Characteristics: Damaged or destroyed tissue (e.g., cornea, mucous membrane, integumentary, or subcutaneous)
Related Factors:
- Mechanical (e.g., pressure, shear, friction);
- radiation (including therapeutic radiation);
- nutritional deficit or excess;
- thermal (temperature extremes);
- knowledge deficit;
- irritants, chemical (including body excretions, secretions, medications);
- impaired physical mobility;
- altered circulation;
- fluid deficit or excess
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
- Tissue Integrity: Skin and Mucous Membranes
- Wound Healing: Primary Intention
- Wound Healing: Secondary Intention
Client Outcomes
- Reports any altered sensation or pain at site of tissue impairment
- Demonstrates understanding of plan to heal tissue and prevent injury
- Describes measures to protect and heal the tissue, including wound care
- Wound decreases in size and has increased granulation tissue
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
- Incision Site Care
- Pressure Ulcer Care
- Skin Care: Topical Treatments
- Skin Surveillance
- Wound Care
Read More : Nursing Interventions and Rationales