Damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, blood vessels, lymphatic tissue, bone, cartilage, joint capsule, and/or ligament

• Anemia
• Cardiovascular diseases
• Clostridium difficile infection
• Critical illness
• Decreased level of consciousness
• Decreased serum albumin level
• Decreased tissue oxygenation
• Decreased tissue perfusion
• Hemodynamic instability
• Immobilization
• Medical devices
• Metabolic diseases
• Nervous system diseases
• Neurodevelopmental disorders
• Pharmaceutical preparations
• Surgical procedures

• History of peripheral vascular disease or surgery
• Age
• Gender
• Mobility status, including range of motion
• Integumentary status, including color, skin care practices, temperature, tenderness, texture, turgor, and edema
• Cardiovascular status, including blood pressure, cardiac output, patient and family history of cardiovascular disease, peripheral pulses, and smoking history
• Nutritional status, including dietary patterns, laboratory tests, serum lipid level, serum protein level, and change from normal weight
• Neurologic status, including motor function and sensory pattern

• Abnormal tissue growth
• Abscess
• Acute pain
• Altered skin color
• Bleeding
• Decreased range of motion
• Difficulty bearing weight
• Dry eye
• Excessive exudate
• Hematoma
• Impaired skin integrity
• Inadequate balance
• Localized area hot to touch
• Localized deformity
• Localized loss of hair
• Localized numbness
• Localized swelling
• Muscle spasm
• Muscle weakness
• Non-viable tissue
• Persistent erythema
• Pressure injury
• Stiffness
• Tingling sensation
• Tissue exposure below the epidermis

• Patient will attain relief from immediate signs and symptoms (pain, ulcers, color changes, and edema).
• Patient will maintain collateral circulation.
• Patient will voice intent to stop smoking.
• Patient will voice intent to follow specific management routines after discharge.

Suggested NOC Outcomes

• Provide scrupulous foot care. Administer and monitor treatments according to institutional protocols. Foot care prevents fungal infections and ingrown toenails, stimulates circulation, and allows detection of signs and symptoms you should immediately report to the physician.
• Use padding, special mattresses, and support devices if needed. These measures reduce undue pressure and decrease the risk of impaired tissue integrity.
• Instruct patient to avoid pressure on popliteal space. For example, say “Don't cross your legs or wear constrictive clothing” to avoid reducing arterial blood supply and increasing venous congestion.
• Encourage adherence to an exercise regimen as tolerated. Exercise improves arterial circulation and venous return by promoting muscle contraction and relaxation.
• Educate patient about risk factors and prevention of injury. Refer patient to a smoking cessation program. Teaching about factors influencing peripheral vascular disease and prevention of tissue damage helps prevent complications.
• Maintain adequate hydration. Monitor intake and output and record daily weight. Adequate hydration reduces blood viscosity and decreases the risk of clot formation.
• If patient has venous insufficiency, apply antiembolism stockings or intermittent pneumatic compression stockings as prescribed, removing them for 1 hour every 8 hours or according to institutional protocol. Elevate patient's feet when sitting and elevate foot of bed 6 to 9 inches (15 to 20.5 cm) when lying down. These measures promote venous return and decrease venous congestion in lower extremities.
• If patient has arterial insufficiency, elevate the head of the bed 6 to 9 in (15 to 20.5 cm) when lying down to increase arterial blood supply to extremities.

Suggested NIC Interventions

• Patient attains relief from immediate symptoms.
  • Patient's feet show no signs of infection, ingrown toenails, or impaired circulation.
  • Patient maintains normal skin turgor.
  • Patient's mucous membranes remain moist.
  • Patient maintains balanced intake and output.
  • Patient's weight remains stable.
• Patient's vital signs remain within normal parameters.
• Patient uses interventions (antiembolism stockings or intermittent pneumatic compression stockings, elevation of feet, and elevation of head of bed) to promote arterial and venous circulation.
• Patient states rationale for quitting smoking and begins smoking cessation program.
• Patient describes plan to incorporate prescribed treatment program into postdischarge routine, including avoiding risk factors and activities that contribute to vascular compression (such as popliteal compression, leg crossing, and wearing constrictive clothing), following exercise program, and practicing foot care.

• Patient's expressions of feelings about current situation
• Observations of skin color, turgor, temperature, and ulcer size
• Patient's response to nursing interventions
• Evaluations for expected outcomes

• Avşar, P., & Karadağ, A. (2018). Efficacy and cost-effectiveness analysis of evidence-based nursing interventions to maintain tissue integrity to prevent pressure ulcers and incontinence-associated dermatitis. Worldviews on Evidence-Based Nursing, 15(1), 54-61. doi:10.1111/wvn.12264
• Chantal Magalhães da Silva, N., de Souza Oliveira, K. A. R., Moorhead, S., Pace, A. E., & Carvalho, E. (2017). Clinical validation of the indicators and definitions of the nursing outcome “Tissue integrity: Skin and mucous membranes” in people with diabetes mellitus. International Journal of Nursing Knowledge, 28(4), 165-170. doi:10.1111/2047-3095.12150
• Kottner, J., Sigaudo-Roussel, D., & Cuddigan, J. (2019). From bed sores to skin failure: Linguistic and conceptual confusion in the field of skin and tissue integrity. International Journal of Nursing Studies, 92, 58-59. doi:10.1016/j.ijnurstu.2019.01.007