00046 Deterioration Of Cutaneous Integrity

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: <00046
Nanda label: deterioration of cutaneous integrity
Diagnostic focus: cutaneous integrity
Approved 1975 • Revised 1998, 2017, 2020 • Level of evidence 3.2

NANDA Nursing Diagnosis Definition

The nursing diagnosis « deterioration of cutaneous integrity is defined as: alteration of the epidermis and/or dermis.

Definite characteristics

  • worn skin
  • Abscess
  • Acute pain
  • Skin coloration alteration
  • Turgity alteration
  • bleeding
  • Ampoule
  • Descamination
  • Skin surface interruption
  • Dry skin
  • Excoriation
  • Strange subjects that pierce the skin
  • Hematoma
  • Hot localized area to touch
  • Skin maceration
  • Pruritus

Related factors

External factors

  • Excessive humidity
  • 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 physical activity
  • Decrease in physical mobility
  • edema
  • Inappropriate adhesion to the incontinence treatment regime
  • Inappropriate knowledge about the maintenance of tissue integrity
  • Inappropriate knowledge about the protection of tissue integrity
  • Malnutrition
  • Psychogenic factor
  • Automutilation
  • smoking
  • Inappropriate use of substances
  • Electrolytes-water imbalance

Risk population

  • People with extreme ages
  • People in intensive care units
  • People in long -stay residences
  • People in residences of palliative care
  • People who receive home care

Associated problems

  • Altered pigmentation
  • Anemia
  • Cardiovascular disease
  • Decrease in the level of consciousness
  • Decrease in tissue oxygenation
  • Decrease in tissue perfusion
  • Diabetes mellitus
  • Hormonal changes
  • Immobilization
  • Immunodeficiency
  • Metabolism deterioration
  • Infections
  • Medical devices
  • Neoplasms
  • Peripheral neuropathy
  • Pharmacological preparations
  • punctures
  • Sensitivity disorders

Suggestions of use

  • The diagnosis deterioration of skin integrity is not specific. A deterioration of skin integrity can be a surgical incision, abrasion, blisters or recumbent ulcers. When using this label, the type of deterioration in the problem must be specified, and not in the etiology.

Note : In the following example, dermal ulcer is a specific type of deterioration of skin integrity and not a cause:

  • Correct: deterioration of skin integrity: dermal ulcer related to complete immobilization
  • Incorrect: deterioration of skin integrity related to dermal ulcer
  • When an ulcer extends beyond the epidermis, tissue integrity deterioration should be used instead of deterioration from cutaneous integrity. Deeper ulcers may require a method of collaboration (that is, surgical treatment). The diagnosis of skin integrity as a label for a surgical incision should not be used, since there are no independent nursing actions to treat this type of “deterioration” and the condition is usually self -limited. Regular nursing care in the case of surgical incision consists of preventing and detecting infections; Therefore, the diagnosis of surgical incision infection or the problem of collaboration of possible surgical complication could be used: Incision infection instead of deterioration of skin integrity.

Suggested alternative diagnostics

  • Infection, risk of
  • Cutaneous integrity, risk of deterioration of
  • Tissue integrity, deterioration of the

NOC Results

  • Wound healing: First intention: degree of regeneration of cells and tissue after an intentional closure
  • Wound healing: Second intention: degree of regeneration of cells and tissue in an open wound
  • Burn healing: degree of healing of an area with burns
  • Tissue integrity: mucous skin and membranes: intact structure and normal physiological function of the skin and mucous membranes
  • Allergic response: Located: Severity of the hypersensitive immune response located before an environmental (exogenous) antigen determined

Evaluation objectives and criteria

  • demonstrates tissue integrity: mucous skin and membranes, as manifested by the following indicators (specify from 1 to 5: severely, substantially, moderately, slightly or not compromised):
    • Temperature, elasticity, hydration and cutaneous sensitivity
    • Tissue perfusion
    • Cutaneous integrity
  • Demonstrates healing wounds: First intention, as manifested by the following indicators (specify from 1 to 5: none, limited, moderate, substantial or extensive):
    • Cutaneous approach
    • Approach of the wound edges
    • Cicatrix formation
  • Demonstrates healing wounds: First intention, as manifested by the following indicators (specify from 1 to 5: extensive, substantial, moderate, limited or none):
    • Cutaneous erythema in the surrounding area
    • Fetid smell of the wound
  • Demonstrates healing wounds: Second intention, as manifested by the following indicators (specify from 1 to 5: none, limited, moderate, substantial or extensive):
    • Granulation
    • Cicatrix formation
    • Wound size reduction
  • Other examples

    • The patient and relatives demonstrate an optimal routine of skin care or a wound
    • Minimum purulent drainage (or other) or smell of the wound
    • Absence of macerated skin or ampoules
    • Absence or low levels of necrosis, scales, grooves, weakening or formation of fistula
    • Reduction of cutaneous erythema and around the wound

    NIC Interventions

    • Medication administration: preparation, administration and evaluation of the effectiveness of prescribed and non -prescribed drugs
    • 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 facilitation of their healing
    • 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
    • Pruritus management: prevention and treatment of itching
    • Skin surveillance: Patient data collection and analysis to maintain the integrity of skin membranes and mucous membranes

    Nursing Activities

    • Also see the nursing activities corresponding to the risk of deterioration of skin integrity.

    Valuations

    • Assess the operation of equipment such as pressure relief devices, including static air mattresses, pressure relief therapy, high viscosity micro fluid therapy and water bed
    • (NIC) Incision site care: Inspect the incision site to detect redness, inflammation, or signs of dehiscence or evisceration
    • (NIC) Wound care:
      • Inspect the wound on each bandage change
      • Monitor the characteristics of the wound, such as drainage, color, size and smell
      • Monitor the following aspects of the wound:
      • Location, dimensions and depth
      • Presence and appearance of the exudate, including tenacity, color and smell
      • Presence or absence of granulation or epithelization
      • Presence or absence of necrosed tissue; Describe the color, smell and quantity
      • Presence or absence of symptoms of local infection of the wound (pain to touch, edema, pruritus, induration, high temperature, foul smell, runs, exudate)
      • presence or absence of weakening or formation of fistula

    Patient and family education

    • Teach to perform the care of surgical incision, including the signs and symptoms of infection, the methods to keep the incision dry during the bathroom, as well as the reduction of damage to the incision

    Collaboration activities

    • Consult a nutritionist about foods rich in protein, minerals, calories and vitamins
    • Consult a doctor about the use of enteral food or parenteral nutrition to increase the wound healing potential
    • Channel with a nursing professional specialized in stomata to obtain help with the valuation, planning, treatment and documentation of wound care or cutaneous damage
    • (NIC) Wound care: Apply an electrical stimulation unit or TENS, to improve the healing of the wound, as required to »
    • Evaluate topical bandages and treatment measures, which may include hydrocolloid bandages, hydrophilic bandages, absorbent bandages, etc.
    • Establish a routine of skin or wound that could include the following:
    • Frequent movement and change of position of the patient
      • Keep the surrounding tissue free of excessive humidity and drainage
      • Protect the patient from fecal and urinary pollution
      • prevent other excretions from the wound and drainage probes to come into contact with the wound
    • Clean and bandage the surgical incision zone through the following principles of sterility or medical asepsis, as required:
      • Use disposable gloves (sterilized, if necessary)
      • Clean the incision from the “clean” area to the “dirty” area using a soap for each cleaning
      • Clean around the staples or suture areas with an applicator with sterilized cotton tip
      • Clean the remains of drainage, from the center out, with a circular movement
      • Apply an antiseptic ointment, as indicated
      • Change the bandage to adequate intervals or leave the incision exposed, as indicated
    • (NIC) Wound care:
      • Remove the bandage and adhesive tape
      • Clean with normal saline solution or a non -toxic cleaner, as required
      • Place the affected area in a pressure tub, as required
      • Manage care for skin ulcers, as required
      • Place the wound so that the tension is avoided, as required
    • Administer IV care, Hickman catheter, or central venous line in the area, according to proceeding
    • Give massage to the area surrounding the wound to stimulate the circulation

    At home

    • The above activities are suitable for home use
    • Establish a management of the case, or channel the patient with a health professional in wounds or stomata, if necessary
    • (NIC) Skin surveillance: instruct a relative and the caregiver about the signs of skin damage, as required
    • (NIC) Wound care: instruct the patient or family members about wound care procedures