00046 Impaired skin integrity

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00046 Impaired skin integrity

Definition of the NANDA label

State in which the individual presents alterations of the epidermis, the dermis or both.

Altered epidermis and/or dermis.

Defining characteristics

• Alteration of the surface of the skin (epidermis).
• Destruction of the layers of the skin (dermis).
• Invasion of body structures.

Related factors

External

• Alteration of the state of liquids.
• Hyperthermia or hypothermia.
• Contact with chemical agents.
• Humidity.
• Radiation.
• Physical immobilization.
• Medicines.
• Mechanical factors:
– Shear forces.
– Pressure.
– Fasteners.
• Extreme ages.

Internal

• Alteration of metabolic state.
• Bony prominences.
• Immune deficiency.
• Alteration of sensitivity.
• Development factors.
• Nutritional alteration (obesity, anorexia).
• Pigmentation disorders.
• Altered circulation.
• Variations in elasticity.
• Alteration in the state of liquids.

At risk population

• Extremes of age

Associated condition

• Alteration in metabolism
• Alteration in pigmentation
• Immunodeficiency
• Impaired circulation
• Alteration in sensation
• Alteration in skin turgor
• Arterial puncture
• Hormonal change
• Pharmaceutical agent
• Radiation therapy
• Vascular trauma

NOC

• Tissue integrity: skin and mucous membranes.
• Wound healing: 1st, 2nd intention.

NIC

• Wound care.
• UPP care.
• Prevention of UPPs.
• Care of the incision site.
• Postural change.
• Care of bowel incontinence.
• Surveillance of the skin.
• Pressure management.
• Nutritional therapy.
• Circulatory precautions.
• Incident report.

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