Definition of the NANDA label
State in which the individual experiences a lesion of the mucous or corneal membranes, integumentary or subcutaneous tissue. It is a situation in which a body tissue is altered.
Damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament.
Tissue destruction injury (eg, cornea, mucous membrane, intergumentary or subcutaneous tissue).
• Altered blood circulation.
• Excess or deficit of body fluids.
• Nutritional excess or deficit.
• Degradation of physic movility.
• Side effects of radiation (including therapeutic).
• Exposure to irritating chemicals (including body excretions or secretions and medications).
• Exposure to mechanical factors (friction, pressure).
• Exposure to extreme temperatures.
• Lack of knowledge.
At risk population
• Extremes of age
• Extremes of environmental temperature
• Exposure to high-voltage power supply
• Alteration in metabolism
• Alteration in sensation
• Arterial puncture
• Impaired circulation
• Impaired mobility
• Peripheral neuropathy
• Pharmaceutical agent
• Radiation therapy
• Surgical procedure
• Vascular trauma
• Wound healing: 1st, 2nd intention.
• Tissue integrity: skin and mucous membranes.
• Wound care.
• Care of the incision site.
• Eye care.
• Maintenance of oral health.
• Prevention of UPP.
• Postural change.
• Care of bowel incontinence.
• Surveillance of the skin.
• Pressure management.
• Nutritional therapy.
• Circulatory precautions.
• Incident report.