What factors affect skin integrity?
8 rows · Nursing Diagnosis: Impaired skin integrity (pressure ulcers) secondary to decreased ...
What is the goal for impaired skin integrity?
Mar 14, 2022 · Nursing Plan 1 – Pressure ulcers/Bedsores. Diagnosis: Pressure ulcers causing impaired skin integrity due to immobility as evidenced by the presence of stage 3 pressure ulcers on the sacrum. Outcome: The bedsore will show optimal healing and development of further bedsores will be prevented. Intervention.
How to prevent impaired skin integrity?
Suspected Deep tissue injury: – Skin is intact; appears purple or maroon. – Blood filled tissue due to underlying tissue damage. – Affected area may have felt firm, boggy, mushy, warmer, or cooler to touch. Stage 1. – Skin is intact but red and non-blanchable. – Area is usually over a bony prominence. Stage 2.
What is risk for impaired skin integrity?
Dec 04, 2019 · Impaired Skin Integrity: Impaired skin integrity nursing diagnosis helps develop an effective skin integrity care plan. As we all know, that skin is safeguarding our body from all external infections that are present in heat & light or accidents etc. Skin integrity can be defined as skin strength and health.
What are several common nursing diagnosis related to the skin?
What are the nursing responsibilities related to skin integrity?
What is impaired skin integrity evidenced by?
What are the nursing diagnosis for wound?
Rubor, or the presence of redness. Calor, or the increased heat in the affected area. Tumor, or observance of swelling on the affected site. Dolor, or pain on or around the wound.
What are the nursing interventions for impaired skin integrity?
| Impaired Skin Integrity Nursing Interventions | Rationales |
|---|---|
| Encourage patient to avoid wearing constricting clothing | Tight clothing can further irritate skin damage and rashes. |
| Encourage proper hydration | Dehydration can cause further skin injury due to skin dryness. |
What is risk for impaired skin integrity related to?
What are examples of nursing diagnosis?
- Risk for imbalanced fluid volume.
- Risk for ineffective childbearing process.
- Risk for impaired oral mucous membrane integrity.
What is the nursing diagnosis for infection?
What is psychosocial nursing diagnosis?
What is the difference between impaired tissue integrity and impaired skin integrity?
Why is impaired skin integrity a priority?
What is a skin integrity assessment?
Objective Data: assessment, diagnostic tests, and lab values. (Signs)
Tissue damage (integumentary, mucous membranes, corneal, subcutaneous tissue)
Nursing Assessment
Perform a complete body audit on admission and at designated times. Pay special attention to bony prominences that are at high risk for tissue injury.#N#A complete head-to-toe audit provides the nurse with a baseline condition of the skin that can be used for comparison when skin damage is noted.
Nursing Interventions for Impaired Skin Integrity
Inspect the affected site at least once per day. Note changes such as color changes, redness, swelling, temperature, and pain. Pay attention if the patient notices changes in sensation and pain.#N#Regular assessments allow the healthcare team to catch deteriorating wound conditions early and adjust treatment as necessary.
Patient Teaching
Discourage the patient from rubbing and scratching the affected area.#N#Friction can make already injured tissue worse. Bacteria could be introduced into open wound tissue and prolong the healing process.
What is impaired skin integrity?
Impaired skin integrity is meant by “damage to skin tissues e.g., subcutaneous, corneal or membrane tissues, etc. If you are having trouble while moving from one place to another, you might be suffering from impaired skin issues.”.
How to avoid skin damage?
help you to avoid skin damages and can lead you to design impaired skin. integrity nursing care plans. Examine the status of the patient’s skin. Check that either client has healthy skin i.e., free from wounds, outbreaks, cuts, rashes, or damaged skin. Aged individual’s skin has reduced elasticity and has less moisture, ...
Why is my skin red?
Check any fracture, muscle stretch or sacrum, etc. because areas that have been stretched are highly leading toward skin integrity problems. Light skin individuals might have a red spot on the affected area, and dark skin tones may have blue, red, or purple color on skin affected surfaces.
How to treat a swollen skin?
Clean your skin twice a day with normal water. Moisture and dry the skin, especially bony prior. Such interventions resist skin injuries. To enhance the perfusions of skin, make sure to massage your skin daily around affected areas.
What causes skin integrity to be impaired?
Common causes of impaired skin integrity is friction which involves rubbing heels or elbows toward bed linen and moving the patient up in bed without the use of a lift sheet.
What is skin integrity?
Skin integrity relates to skin health. A skin integrity problem might indicate the skin is damaged, exposed to injury or inefficient to repair and recover normally. The key marker of quality care is the maintenance of skin integrity and prevention of pressure ulcers. With this, the nurse must be aware of identifying at-risk individuals and ...
What is the importance of skin integrity?
The skin is the largest organ in the human body and is a protective barrier. It protects the body from heat, light, injury, and infection. Skin integrity relates to skin health. A skin integrity problem might indicate the skin is damaged, exposed to injury or inefficient to repair and recover normally. The key marker of quality care is the ...
Does urine cause skin breakdown?
Stool may contain enzymes that cause skin breakdown. The urea in urine turns into ammonia within minutes and is caustic to the skin. Use of diapers and incontinence pads hastens skin breakdown. Assess for a history or presence of AIDS or other immunological problems.
Can steroid use cause skin to be papery?
Long-term steroid use may leave skin papery thin and prone to injury. Reassess the skin regularly and whenever the patient’s condition or treatment plan results in an increased number of risk factors. The incidence and onset of skin breakdown is directly related to the number of risk factors present.
Scenario
An 93 year old female presents to the ER with her family. The patient looks very thin and malnourished. Pt’s weight is 95 lb and height is 5′ 6. Pt has advance stage of Alzheimer’s and is aphasic. Pt is also a type 1 Diabetic. Contractures are noted in both upper extremities.
Nursing Diagnosis
Impaired Skin Integrity related to malnutrition and pressure ulcers as evidence by disruption of epidermal and dermal tissues.
Subjective Data
Unable to walk for the past year and has not be able to eat for the past week.
Objective Data
Pt’s weight is 95 lb and height is 5′ 6. Pt has advance stage of Alzheimer’s and is aphasic. Pt is also a type 1 Diabetic. Contractures are note in both upper extremities. stage 3 pressure ulcer on her right heel and sacral area. The wound on the heel is draining purulent yellow drainage and is 3 inches wide and 1 1/2 inches deep.
Signs and Symptoms
Goals and Outcomes
- The following are the common goals and expected outcomesfor impaired tissue integrity. Use them in writing your short term or long term goals for your impaired tissue integrity care plan: 1. Patient reports any altered sensation or pain at site of tissue impairment. 2. Patient demonstrates understanding of plan to heal tissue and prevent injury. 3. Patient describes measures to protec…
Nursing Assessment and Rationales For Impaired Tissue Integrity
- Assessment is required to recognize possible problems that may have lead to Impaired Tissue Integrity and identify any episode that may transpire during nursing care. 1. Determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, leg ulcer). Prior assessmentof wound etiology is critical for the proper identification of nursing interventions. 2. …
Nursing Interventions and Rationales For Impaired Tissue Integrity
- The following are the therapeutic nursing interventions for Impaired Tissue Integrity nursing diagnosis: 1. Provide tissue care as needed. Each type of wound is best treated based on its etiology. Skin wounds may be covered with wet or dry dressings, topical creams or lubricants, hydrocolloid dressings (e.g., DuoDerm), or vapor-permeable membrane d...
Recommended Resources
- Recommended nursing diagnosis and nursing care plan books and resources. Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy. 1. Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition) An awesome book to hel…
See Also
- Other recommended site resources for this nursing care plan: 1. Nursing Care Plans (NCP): Ultimate Guide and Database Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch. 2. Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing Our comprehensive guid…
References and Sources
- Recommended resources for the nursing diagnosis impaired tissue integrity and care plan: 1. Baranoski, S., & Ayello, E. A. (2008). Wound care essentials: Practice principles.Lippincott Williams & Wilkins. 2. Berman, A., Snyder, S. J., Kozier, B., Erb, G. L., Levett-Jones, T., Dwyer, T., … & Parker, B. (2014). Kozier & Erb’s Fundamentals of Nursing Australian Edition (Vol. 3).Pearson Higher Ed…
Causes
Signs and Symptoms
- Subjective:
1. Pain 2. Itching 3. Numbness to affected and surrounding skin - Objective:
1. Changes to skin color (erythema, bruising, blanching) 2. Warmth to skin 3. Swelling to tissues 4. Observed open areas or breakdown, excoriation
Expected Outcomes
- Patient will maintain intact skin integrity
- Patient will experience timely healing of wounds without complications
- Patient will demonstrate effective wound care
- Patient will verbalize proper prevention of pressure injuries
Nursing Care Plans For Impaired Skin Integrity
- Nursing Care Plan 1
Nursing Diagnosis:Impaired skin integrity related to immobility as evidenced by stage 2 pressure ulcer to the sacrum Desired outcome:Patient will not experience worsening of pressure ulcer - Nursing Care Plan 2
Nursing Diagnosis: Impaired skin integrity related to decreased skin sensation secondary to diabetic neuropathy as evidenced by redness and an open area to the left lower leg Desired outcome: Patient will verbalize understanding of daily skin inspection
References and Sources
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales(11th ed.). F. A. Davis Company.
- Hovan, H. (2021, January 7th). Understanding the Braden Scale: Focus on Sensory Perception (Part 1). Wound Source. Retrieved October 11th, 2021, from https://www.woundsource.com/blog/understanding-...
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales(11th ed.). F. A. Davis Company.
- Hovan, H. (2021, January 7th). Understanding the Braden Scale: Focus on Sensory Perception (Part 1). Wound Source. Retrieved October 11th, 2021, from https://www.woundsource.com/blog/understanding-...
- Posthauer, M. E. (2006, March). Hydration Does It Play a Role in Wound Healing? Advances in Skin & Wound Care. Retrieved October 11th, 2021, from https://journals.lww.com/aswcjournal/fulltext/2006/...
- Stoma Skincare. (n.d.). Bladder and Bowel Community. https://www.bladderandbowel.org/bowel/stoma/stoma-skincare/
