00044 Deterioration Of Tissue Integrity

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: <00044
Nanda label: tissue integrity deterioration
Diagnostic focus: tissue integrity
Approved 1986 • Revised 1998, 2013, 2017, 2020 • Evidence level 3.2

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « deterioration of tissue integrity is defined as: lesion of the mucous membrane, cornea, tegumentary system, muscle fascia, muscle, tendon, bone, cartilage, articular capsule and/or ligament.

Definite characteristics

  • Abscess
  • Acute pain
  • bleeding
  • Decrease in muscle strength
  • Decrease in the amplitude of movements
  • Difficulty to support weight
  • Ocular dryness
  • Hematoma
  • Deterioration of cutaneous integrity
  • Hot localized area to touch
  • Located deformity
  • Localized hair loss
  • Located numbness
  • Located swelling
  • Muscle spasm
  • Informs lack of balance
  • Informs a tingling sensation
  • Rigidity
  • Exhibition of tissues below the epidermis

Related factors

External factors

  • Excretions
  • Humidity
  • Hyperthermia
  • Hypothermia
  • Inadequate knowledge of the caregiver (a) on the maintenance of tissue integrity
  • Inadequate knowledge of the caregiver (a) on the protection of tissue integrity
  • Inappropriate use of chemical agent
  • Bone prominence pressure
  • Psychomotor agitation
  • Secretions
  • Hear forces
  • Friction on the surface
  • Use of bedding with insufficient moisture absorption capacity

Internal factors

  • Body mass index above the normal range according to age and sex
  • Body mass index below the normal range according to age and sex
  • Decrease in flicker frequency
  • Decrease in physical activity
  • Liquid imbalance
  • deterioration of physical mobility
  • Postural balance deterioration
  • Inappropriate adhesion to the incontinence treatment regime
  • Inadequate management of the blood glucose level
  • Inappropriate knowledge about the maintenance of tissue integrity
  • Inappropriate knowledge about the restoration of tissue integrity
  • Inappropriate care of ostomy
  • Malnutrition
  • Psychogenic factor
  • Automutilation
  • smoking
  • Inappropriate use of substances

Risk population

  • Homeless people
  • People with extreme ages
  • People exposed to extreme environmental temperatures
  • People exposed to a high voltage power supply
  • People participating in contact sports
  • People participating in winter sports
  • People with family history of bone fracture
  • People with a history of bone fracture

Associated problems

  • Anemia
  • Autistic spectrum disorder
  • Cardiovascular disease
  • Chronic neurological problems
  • Severe condition
  • Decrease in the level of consciousness
  • Decrease in serum albumin level
  • Decrease in tissue oxygenation
  • Decrease in tissue perfusion
  • Hemodynamic instability
  • Immobilization
  • Intellectual disability
  • Medical devices
  • Metabolic diseases
  • Peripheral neuropathy
  • Pharmacological preparations
  • Sensitivity disorders
  • Surgical procedures

Suggestions of use

  • 1. If the integrity of the tissue is at risk due to immobility and if other systems are also at risk, consider the use of disuse syndrome.
  • 2. If the necessary defining characteristics are present, use the most specific problems of deterioration of the oral mucosa or deterioration of skin integrity. Deterioration of tissue integrity should be used only when the damage is not found in the skin or in the mucous membranes.
  • 3. The deterioration of tissue integrity to rename a surgical incision or an ostomy should not be used.

Suggested alternative diagnostics

  • Cutaneous integrity, deterioration of the
  • Oral mucosa, deterioration of the
  • Surgical recovery, delay in
  • disuse syndrome, risk of

NOC Results

  • Self -care of ostomy: personal actions to keep the stoma for elimination
  • Wound healing: First intention: scope of cell regeneration and tissue after an intentional closure
  • Wound healing: Second intention: Cell regeneration and tissue regeneration in an open wound
  • Tissue integrity: mucous skin and membranes: intact structure and normal physiological function of the skin and mucous membranes
  • Allergic response: Located: Severity of the immune response of hypersensitivity located before an environmental (exogenous) environmental antigen

Evaluation objectives and criteria

  • Also see the evaluation objectives/criteria for cutaneous integrity, deterioration of the.

  • demonstrates tissue integrity: skin and mucous membranes, which is manifested by the following indicators (specify from 1 to 5: severely, substantially, moderately, slightly or not compromised):
    • Skin integrity
    • Tissue texture and thickness
    • Tissue perfusion
  • Other examples

    • Absence of signs or symptoms of infection
    • Absence of injuries
    • Absence of necrosis

    NIC Interventions

    • Ostomy care: Maintenance of elimination through a stoma and care of the surrounding tissue
    • Skin care: Topical treatments: application of topical substances or device manipulation to facilitate skin integrity and reduce its rupture
    • Wound care: prevention of wound complications and help for cure
    • Pressure ulcers care: Facilitation of the healing of recumbency ulcers
    • Incision site care: cleaning, surveillance and promotion of healing a closed wound by suture, clips or staples
    • Pressure management: pressure reduction on body parts
    • Oral health maintenance: maintenance and promotion of the patient’s oral and dental hygiene that is at risk of developing oral or dental lesions
    • Prevention of pressure ulcers: Prevention of recumbent ulcers in an individual who has a high risk of developing them
    • Infection protection: Prevention and early detection of infections in a risk patient
    • Skin surveillance: Patient data collection and analysis to maintain the integrity of the skin and mucous membranes

    Nursing Activities

    • For specific nursing activities, see the nursing activities of the following diagnoses:
    • Infection, risk of
    • Cutaneous integrity, deterioration of the
    • Cutaneous integrity, risk of deterioration of
    • Oral mucosa, deterioration of the
    • Inephic peripheral tissue perfusion