00047 Risk Of Deterioration Of Cutaneous Integrity

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: <00047
Nanda label: risk of deterioration of cutaneous integrity
Diagnostic focus: cutaneous integrity
Approved 1975 • Revised 1998, 2010, 2013, 2017, 2020 • Evidence level 3.2

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « risk of deterioration of cutaneous integrity is defined as: susceptible to an alteration in the epidermis and/or dermis, which can compromise health. P>

Risk 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 cutaneous integrity
  • Inappropriate knowledge about the protection of cutaneous 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

  • This diagnosis should be used for patients who do not show symptoms but are at risk of developing damage to the skin surface or a deterioration of the skin layers if preventive measures are not taken.
  • The presence of more than one risk factor increases the possibility of skin damage. When there is a risk of deterioration of cutaneous integrity as a result of immobilization, and when other body systems also have a risk of deterioration, the use of the diagnosis of disuse syndrome should be considered.

Suggested alternative diagnostics

  • Cutaneous integrity, deterioration of the
  • disuse syndrome, risk of

NOC Results

To evaluate the real presence of a deterioration of cutaneous integrity, the following result should be used:

  • Tissue integrity: mucous skin and membranes: Structural integrity and normal physiological function of the skin and mucous membranes
  • The following are examples of results related to risk factors:
  • Consequences of immobility: physiological: severity of the risk for physiological functioning due to an impediment of physical mobility
  • Urinary continence: urine removal control from the bladder
  • Risk Control: Sun exposure: Personal actions to prevent or reduce the risks of sun exposure for skin and eyes
  • Nutritional status: point to which nutrients are available to meet metabolic needs
  • Tissue perfusion: peripheral: adequacy of blood flow through the small vessels of the limbs, to maintain the tissue function

Evaluation objectives and criteria

  • Demonstrates consequences of immobility: physiological, as manifested by the following indicators (specify from 1 to 5: severe, substantial, moderate, light or none): recumbent ulcers
  • demonstrates tissue integrity: skin and mucous membranes, as manifested by the following indicators (specify from 1 to 5: severely, substantially, moderately, slightly or not compromised):
    • Sensitivity
    • Elasticity
    • Hydration
    • Texture
    • Cutaneous integrity
  • Other examples

    • demonstrates an effective routine of skin care
    • Present strong and symmetrical pulses
    • Normal skin color
    • Warm skin
    • Absence of pain in the limbs
    • Eat food properly to encourage cutaneous integrity

    NIC Interventions

    • Circulatory care: Arterial insufficiency: surveillance of arterial circulation
    • Circulatory care: venous insufficiency: Venous circulation surveillance
    • Intestinal incontinence care: Surveillance of fecal continence and maintenance of the integrity of the perianal skin
    • Incision site care: cleaning, surveillance and favoring the healing of a closed wound by suture, clips or staples
    • Bed Care: Improvement of comfort and safety, as well as prevention of complications of a patient who cannot get out of bed
    • Nutrition management: Help with or provision of a balanced diet in food and liquids
    • Pressure management: reduce the pressure in different areas of the body as much as possible
    • Prevention of pressure ulcers: Prevention of recumbent ulcers in an individual who has a high risk of developing them
    • Skin surveillance: Patient data collection and analysis to maintain the integrity of the skin and mucous membranes

    Nursing Activities

    • Nursing activities for this diagnosis consist mainly in surveillance and prevention.
    • All patients at risk

    Valuations

    • In admission and whenever physical conditions change, assess the risk factors that can cause skin break (for example, continuous bed or in a chair, inability to move, fecal or urinary incontinence, malnutrition and Reduction of mental consciousness)
    • Identify pressure and friction sources (for example, plaster, bed, clothing)
    • (NIC) Prevention of pressure ulcers:
      • Use an accepted tool to assess patient risk factors (for example, Braden scale)
      • Inspect the skin located on bone prominences and other pressure points when changing position to the patient, or at least once a day
    • (NIC) Skin surveillance:
      • Monitor the following leather factors and mucous membranes:
      • Eruptions and abrasions
      • Color and temperature
      • Drying and excessive humidity
      • Zones with discoloration, bruises and ruptures

    Collaboration activities

    • Channel with a nursing professional specialized in stomata to obtain help in the prevention, assessment and treatment of skin or wounds

    Others

    • Use a pressure reduction mattress (for example, polyurethane foam mattress)
    • Do not give massage in bone prominences
    • (NIC) Prevention of pressure ulcers:
      • Place cubits and heels, as required
      • Keep the bedding clean, dry and without folds
      • Patients with mobility deficit /activity

    Valuations

    • Assess the degree of limitations to move or move in bed

    Others

    • Paddle the edges of the plaster apparatus and traction connections

    for patients confined to a chair:

    • Take into account postural alignment, weight distribution, balance and stability; The relief of pressure when placing patients in chairs or in wheelchairs
    • Make the patient lift weight every 15 minutes, if capable of
    • Use pressure reduction devices for seats; Do not use “dona” -shaped devices

    for patients confined to a bed:

    • Do not place the patient directly on the mound of the hip
    • Raise the bed header a little and during the shortest possible time
    • Use a bed or mattress that reduces the pressure (for example, foam, air, egg basket)
    • Use adequate positioning, transfer and movement techniques
    • Use lifting devices to displace the patient, instead of dragging it, during transfers and position changes
    • (NIC) Prevention of pressure ulcers:
      • Turn the patient each or two hours, as required
      • Provide a trapeze to help the patient lift weight frequently
      • Place pillows to raise the pressure points on the bed
      • Place cubits and heels, as required
      • Patients with incontinence or presence of moisture

    Valuations

    • Assess the need to use permanent probes or condom catheters
    • Check urinary or fecal incontinence every ___________________

    Others

    • Clean the skin when getting dirty
    • Individualize the bathroom schedule, avoid hot water, use soft cleaners
    • Decrease skin to moisture skin
    • (NIC) Prevention of pressure ulcers:
      • Eliminate excessive moisture from the skin due to perspiration, the drainage of the wound and the fecal or urinary incontinence
      • Apply protection barriers, such as creams or compresses that absorb moisture, to eliminate excess moisture, as required
      • Avoid the use of devices in the form of “dona” in the area of ??the sacrum
      • Do not give massage about bone prominences
      • Turn the patient carefully to avoid delicate skin injuries (due to cuts)
      • Patients with nutritional deficit

    Valuations

    • Monitor nutritional status and food intake

    Collaboration activities

    • Consult a nutritionist about foods rich in protein, minerals and vitamins
    • Ask for a medical order for the analysis of transferrin, albumin and concentrate of erythrocytes

    Others

    • Compare the current body weight with the ideal weight
    • Investigate the factors that put an apparently adequate nutrition (especially protein or calories) and offer help for food time
    • (NIC) Prevention of pressure ulcers: guarantee an adequate intake, especially protein, vitamins B and C, iron and calories, with the use of supplements, as required

    At home

    • Previous activities can adapt to home care