![]() Assess changes in body temperature, specifically increased body temperature.įever is a systemic manifestation of inflammation and may indicate the presence of infection. Serous exudate from a wound is a normal part of inflammation and must be differentiated from pus or purulent discharge present in the infection.Ĥ. An odor may result from the presence of infection on the site it may also be coming from necrotic tissue. Pale tissue color is a sign of decreased oxygenation. These findings will give information on the extent of the impaired tissue integrity or injury. Assess characteristics of the wound, including color, size (length, width, depth), drainage, and odor. Redness, swelling, pain, burning, and itching are indications of inflammation and the bodys immune system response to localized tissue trauma or impaired tissue integrity.ģ. Assess the site of impaired tissue integrity and its condition. Prior assessment of wound etiology is critical for the proper identification of nursing interventions.Ģ. Determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, leg ulcer). Nursing Assessment and Rationales for Impaired Tissue IntegrityĪssessment is required to recognize possible problems that may have lead to Impaired Tissue Integrity and identify any episode that may transpire during nursing care.ġ. Patients wound decreases in size and has increased granulation tissue.Patient describes measures to protect and heal the tissue, including wound care. ![]()
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