00047 Risk for impaired skin integrity

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00047 Risk for impaired skin integrity

Definition of the NANDA label

State in which the individual’s skin is in danger of being altered.

Susceptible to alteration in epidermis and/or dermis, which may compromise health.

Risk factors

External (environmental)

• Irritating chemicals.
• Body excretions or secretions.
• Mechanical factors (pressure, shear, clamping).
• Radiation.
• Physical immobilization.
• Humidity.
• Hypothermia or hyperthermia.
• Extremes of age.

Internal (individual)

• Alteration of nutritional status.
• Metabolic disorders.
• Sensory disturbances.
• Development factors.
• Bony prominences.
• Medicines.
• Changes in the elasticity of the skin.
• Psychogenic factors.
• Immunological factors.
• Altered circulation.

At risk population

• Extremes of age

Associated condition

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

NOC

• Tissue integrity: skin and mucous membranes.
• Risk control.
• Hydration.

NIC

• Prevention of UPPS.
• Surveillance of the skin.
• Changes in position.
• Care of bowel incontinence.
• Promotion of exercise.
• Pressure management.
• Nutritional therapy.
• Circulatory precautions.
• Incident report.

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