Aside from that, gastritis and pancreatic damage can result from excessive alcohol use. Educate on recommended diets to control output, Diet considerations may depend on each individual with trial and error. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Date:- PDF Nursing Diagnosis Impaired Skin Integrity Pdf ; (book) The following are the risk factors that can predispose individuals to skin damage: Nursing Diagnosis: Impaired skin integrity related to edema formation secondary to Kawasaki disease as evidenced by bilateral swelling of the legs and feet and small cut on left ankle. Assess and record the integrity of skin. The etiology identifies the contributing or causative factors of the problem. Problems with social interaction and mobility. Patients may have tachycardia and increased blood pressure reading on their vitals. Dependent:-Apply topical lubricants (steroid creams or ointments) immediately after bathing as . It reduces itchiness by lubricating the skin. Removal of scabs prior to applying the topical antibiotic promotes good absorption of the medication. Pain is what the pt. The Braden Scale is an evidence-based tool that predicts the risk for pressure injuries. 5. Ascertain that the patient consumes a nutritionally balanced diet that includes adequate hydration. Nursing Diagnosis: Impaired skin integrity related to immobility as evidenced by stage 2 pressure ulcer to the sacrum, Desired outcome: Patient will not experience worsening of pressure ulcer, Nursing Diagnosis: Impaired skin integrity related to decreased skin sensation secondary to diabetic neuropathy as evidenced by redness and an open area to the left lower leg, Desired outcome: Patient will verbalize understanding of daily skin inspection, Nursing Diagnosis: Impaired skin integrity related to surgical incision and stoma creation to the abdomen, Desired outcome: Patient will verbalize understanding of preventing skin irritation to skin surrounding the stoma. Nursing Diagnosis: Imbalanced Nutrition: Less than the body requirements related to reluctance to consume meals, secondary to malnutrition as evidenced by an imbalance in electrolytes, ineffective healing of wounds, reductions in the level of protein, transferrin, and serum albumin concentration, loss of muscle tone and a weight decrease of less than 20%. 2021 Sep 13;13(9):1454. doi: 10.3390/pharmaceutics13091454. Refer to a wound care specialist.Complicated, infected, or non-healing wounds require treatment at a wound care center with ongoing assessment from a wound care team. Evidence-based Best Practice in Maintaining Skin Integrity Skin is the largest organ in our body which protects from heat, light, injury and . Measure the volume of urine output. Care Plan for nursing diagnosis: Impaired Skin Integrity Iron deficiency causes impaired cognitive function, trouble controlling body temperature, and stomach problems. (adsbygoogle = window.adsbygoogle || []).push({}); - Encourage the patient to perform range of motion exercises.Exercise can help prevent muscle stiffness and improves blood circulation in the affected area. Thus, ensuring that the patient is adequately hydrated minimizes the risk of illness and infection. Radiated skin becomes thin and friable, may have less blood supply, and is at higher risk for breakdown. 2) Risk assessment includes identifying whether a skin break is present or not. 1. Impaired Skin Integrity Concept Map - Nursing Diagnosis - StuDocu Wedge pillows, waffle boots, and gel overlays to beds and chairs can be effective in offloading. Patient will demonstrate interventions that promote wound healing and decrease the risk of infection. Long toenails can cause damage to skin. This can happen as a result of: Individuals who live in poor countries or locations with restricted access to food, People who have gastrointestinal issues, particularly those with malabsorption syndrome, Individuals that are struggling financially. In more serious situations, hospitalization may be necessary. The only thing about pain (because i used that as an answer once and got it wrong) is that our instructors wanted "evidence" that you could. Impaired Skin Integrity related to a surgical incision of the perineum during labor as evidenced by . To keep weight under control while having fun socially, using smart eating strategies, whether dining out or traveling, is advisable. Assist the patient in using assistive devices.Pressure offloading is essential in the management and healing of diabetic foot ulcers. Inadequate or incorrect wound care delays healing and increases the. The patient will report feeling less fatigued and more capable of completing his/her tasks. Areas where skin is stretched tautly over bony prominences are at higher risk for breakdown because the possibility of ischemia to skin is high as a result of compression of skin capillaries between a hard surface (mattress, chair, or table) and the bone. and transmitted securely. Refer the patient to additional sources of information (for overnutrition and malnutrition), such as books, audiotapes, community classes, and other organizations. Vascular problems are worsened by smoking, also, the success of vascular treatments such as angioplasty can be affected if the patient will not stop smoking after having it. Specific symptoms distinguish some forms of undernutrition. Redness and open areas to the skin put the patient at risk for infection such as. Alternative methods of nutrient intake may be necessary if the patient is unable to consume meals to meet their bodys requirements, such as if they have, Having a dietary plan that is both nutritious and well-balanced. Having a calm and comfortable environment can assist the patient in de-stressing and make eating a more pleasurable experience. Semin Oncol Nurs. Clean and dress bedsore as needed. St. Louis, MO: Elsevier. It is also important to remember that certain digestive issues might lead to malnutrition. Individuals who are malnourished may suffer from the following: 5. Silk Fibroin Biomaterials and Their Beneficial Role in Skin Wound Healing. Gardiner L et al Evidence based best practice in. 1-612-816-8773. She earned her BSN at Western Governors University. Check water temperature when washing feet. Disclaimer. High blood sugar levels result from diabetes, a chronic disease that impairs the body's ability to make or use insulin. Patients with diabetes mellitus often experience poor circulation from atherosclerosis and vascular damage, which inhibits wound healing and can lead to tissue necrosis and gangrene. Encourage proper hydration. Kwashiorkor patients experience fluid retention and a protruding abdomen as a result of protein deficiency. Assess patient's ability to move (shift weight while sitting, turn over in bed, move from bed to chair). Consider discussing with a physician to determine nutrient deficiencies. Encourage patient to avoid wearing constricting clothing. Nutritional deficits can make a patient appear lethargic and exhausted. Other signs and symptoms include decreased concentration, paleness, dry skin, confusion, loss of subcutaneous tissue, dullness and brittle hair, swollen tongue, etc. Massaging reddened area may damage skin further. Poor skin turgor, decreased sensations (nerve damage), and poor circulation (lack of blood flow assessed via palpation of pulse sites as well as observed by purplish or ruddy discoloration of lower legs) increase the risk of tissue damage. Obtain a wound swab.A wound can be cultured for the presence of bacteria such as staphylococcus, pseudomonas, etc., to allow for proper antibiotic treatment. The patient can wear slippers indoors. Supplementation should only be done under the guidance of a qualified healthcare provider. Desired Outcome: The patient will be able to experience optimal wound healing and avoid the spread of infection to the rest of the skin to preserve its integrity. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. These may include diseases such as celiac disease, Crohns disease, and systemic infection in the intestines. Chapter 01: Professional Nursing Test Bank MULTIPLE CHOICE 1. 2. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. Risk for impaired skin integrity related to prolonged immobility, poor skin turgor, poor circulation or altered sensation (use one) Objective. The skin is a waterproof, flexible organ that covers the human body. Risk for Infection of a perineal incision could be r/t poor wound appromixation, or contamination of the site with fecal matter. Impaired Skin Integrity - Dermatitis Nursing Care Plans Common Related Factor Defining Characteristics Contact with irritants or allergens Inflammation Dry, flaky skin Erosions, excoriations, fissures Pruritus, pain, blisters Common Expected Outcome Patient maintains optimal skin integrity within limits of the disease, as evidenced by intact skin. Patient will demonstrate timely wound healing without complications. Wound Healing and Skin Integrity: Principles and Practice GOAL: Monitor the condition of skin and risk factors to ensure skin integrity Potential Interventions: Inspect skin daily with cares (done by nursing assistants) Inspect skin weekly by licensed nurse Risk assessment per protocols Documentation of skin integrity concerns (i.e., pressure ulcer) at least weekly :imbar. Isn't it evidenced by seeing the surgical incision? This ensures the continuation of the program. :), I really have no idea about how to classify a woundwe haven't done anything like that. She found a passion in the ER and has stayed in this department for 30 years. Patients who are malnourished tend to have dry, thick skin that is easily bruised; therefore, moisturization is necessary to keep the skins integrity and, as a result, limit the likelihood of infection from occurring. Treatment for malnutrition depends on the type and severity. Avoid rubbing or brisk drying. National Library of Medicine Desired Outcomes. Stumped on Nursing Diagnosis for Episiotomy. Aspirin use may be reduced the risk of Bile duct cancer ! Nursing Diagnosis: Impaired skin integrity (pressure ulcers) secondary to decreased mobility as evidenced by presence of stage 2 pressure ulcer on the sacrum. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. Also, moisturizing the feet helps keep its intact skin integrity. 4. Please read our disclaimer. Nursing diagnoses handbook: An evidence-based guide to planning care. Risk for falls. Anyone with diabetes mellitus can develop a foot ulcer resulting from poor glycemic control, peripheral vascular disease, underlying neuropathy, and poor foot care. Risk Factors: unsteady gait, BP, generalized weakness. Undernutrition. In order to aid patients and healthcare practitioners in diagnosing and treating nutritional deficiencies, it is necessary to understand the signs and symptoms of malnutrition. FOIA Unique Variation of Barber's Disease: A Case Report. XLSX kjc.cpu.edu.cn Background: In aged nursing care receivers, the prevalence of adverse skin conditions such as xerosis cutis, intertrigo, pressure ulcers or skin tears is high. The management of diabetic foot ulcers requires interdisciplinary support from podiatrists, endocrinologists, primary care providers, diabetes educators, nurses, and wound care specialists. pain can be evidenced by grimacing, whincing, or guarding too, "Knowledge Deficit r/t care of episiotomy AEB this being pt's first experience with one, pt asking questions about special care instructions, etc. Risk Factors: bed rest, bowel incontinence. Certain types of malnutrition are more common in some groups than others due to factors such as lifestyle, geography, and access to food. This form of malnutrition is caused by a lack of calories, protein, and micronutrients in the diet. Assessing the changes in the patients vital signs can provide early indications of inadequate circulating fluid. Consult with a prosthetist.In the event that the patient requires amputation, they may be fitted with a prosthetic. Buy on Amazon, Gulanick, M., & Myers, J. L. (2022). (Nursing Care Plans for Impaired Skin Integrity) Nursing Care Plans for Impaired Skin Integrity Nursing Care Plans for Impaired Skin Integrity: Care Plan 3 - Diagnosis: Pressure ulcers / Bedsores. Stoma following surgery should be moist and pink-red in color. Unauthorized use of these marks is strictly prohibited. Buy on Amazon, Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Sutter Health Sacramento - RN Residency 2023. St. Louis, MO: Elsevier. Understanding best practices in addressing skin . 3. Impetigo is an infectious/ communicable skin disease. The twenty-first century clinician has several online, evidence-based tools to assist with optimal treatment plans. To prevent prolonged pressure on one area of the body. Patients skin will remains intact, as evidenced by: no redness over bony prominences, and capillary refill less than 6 seconds over areas of redness. Patient recovery and prognosis can be adversely affected by fluid retention, electrolyte changes, and impaired renal function. Vitamin deficits are also caused by malnutrition. Healthy skin varies from individual to individual, but should have good turgor (an indication of moisture), feel warm and dry to the touch, be free of impairment, and have quick capillary refill (less than 6 seconds). Overall, the most effective treatment options may be contingent on identifying the source of malnutrition. Pressure Ulcer/Pressure Injury Nursing Care Plan - RN speak Impaired Skin Integrity related to the stage 3 ulcer on the right heel as evidenced by the presence of an open wound and the patient's medical history of Type 2 Diabetes. Patients who have trouble digesting or absorbing nutritional components may also suffer from malnutrition. Perform wound care.Perform wound care per the physicians orders. Remind the patient to inspect the feet daily.Patients with neuropathy or peripheral vascular disease may not be able to feel when they have cut their skin. The regular assessment of skin health is part of the daily evaluation healthcare staff make to ensure holistic care. When the infection spreads to the soft tissues and bones, it can lead to lower-limb amputation. Nursing Plan 1 - Pressure ulcers/Bedsores. Assess the patients wound.The color, odor, visibility of bones, and the presence of necrosis must be assessed to determine an appropriate plan of care for the patients condition. a. One of the primary reasons for this is that a persons body is unable to absorb nutrients because food cannot be digested properly. Observe the type of food and volume of fluid consumed by the patient. Maintaining skin integrity in the aged: A systematic review Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac. Patients who cannot reposition themselves should be turned in bed on a schedule at least every 2 hours. Methodologically, I will introduce a breakthrough by linking macroeconomic analysis with an original evidence-based representation of investment decisions based on forward-looking expectations of transition pathways. Nursing Care Plan for: Impaired Skin Integrity, Risk for Skin Breakdown, Altered Skin Integrity, and Risk for Pressure Ulcers. Which statement, if made by the student nurse, indicates that teaching was successful? 3. Review imaging and lab results.If there is a concern for osteomyelitis, MRI is useful for diagnosis. Provide pain relief as needed. It is important to maintain the cleanliness of the affected areas by washing with mild soap and water. Malnutrition Nursing Diagnosis and Nursing Care Plans Obese people who eat largely processed meals may be deficient in nutrients, vitamins, and minerals. 2]. It involves the resection of the gangrenous tissue to prevent further spread of the condition to other vital organs. Some nursing diagnoses which might be appropriate for patients with a medical diagnosis of diabetes mellitus include impaired skin integrity if a superficial rash is present, impaired tissue integrity if a wound is present, deficient knowledge, imbalanced nutrition, and ineffective health maintenance. Nursing diagnoses handbook: An evidence-based guide to planning care. Building trust begins with listening attentively to the patients concerns and questions. 3. Impaired Skin Integrity - Dermatitis UNKLAB NURSING PORTAL It can cause major health problems, such as growth retardation, vision problems, diabetes, and cardiovascular disease. PMC "Risk for Impaired Skin Integrity" is the problem, and "as evidenced by reddened areas of skin on the heels and back" are the defining characteristics of the problem. Assess the extent of skin impairment.Pressure ulcers can be classified as partial thickness, stage 1-4, or unstageable. She has worked in Medical-Surgical, Telemetry, ICU and the ER. Desired Outcome: Patients bedsore will show optimal healing, and further bedsores will be prevented. Alteration/Impairment in Skin Integrity. Maegan Wagner is a registered nurse with over 10 years of healthcare experience. Provide appropriate mattress and cushion. NurseTogether.com does not provide medical advice, diagnosis, or treatment. Mechanical forces (pressure, shear, friction), Acquired immunodeficiency syndrome (AIDS). Patients may not notice if the water is too hot due to reduced sensation. Specializes in Critical Care / Psychiatry. At some point, the bodys metabolism slows down when it reaches a state known as a plateau. This is produced by the body activating a survival mechanism in an attempt to avoid starvation. In order to maintain weight loss in the face of these changes, it is necessary to devise a new plan that is both vigorous and consistent. Impetigo is generally treated through the use of antibiotic therapy. Anna Curran. Pressure release mattresses and cushions are helpful to prevent sores from occurring and they help spread equal pressure to the body when sitting and lying down. The lower the score, the higher the risk of tissue injury. Nursing care plans: Diagnoses, interventions, & outcomes. Observed wounds should be monitored to ensure dressings are intact or that skin breakdown is not worsening, such as increased redness. Educate the patient and caregiver about proper wound hygiene through washing the sores with soap and water. Identify alternatives to the chosen activity program to meet the patients travel and weather conditions, and other concerns. https://www.woundsource.com/blog/understanding-braden-scale-focus-sensory-perception-part-1, https://journals.lww.com/aswcjournal/fulltext/2006/03000/hydration__does_it_play_a_role_in_wound_healing_.7.aspx, https://www.bladderandbowel.org/bowel/stoma/stoma-skincare/, Impaired Gas Exchange Nursing Diagnosis & Care Plan, Risk for Falls Nursing Diagnosis & Care Plan. . Encourage mobility Physical activity helps promote circulation and fluid drainage. @article{osti_6035610, title = {Impaired skin integrity related to radiation therapy}, author = {Ratliff, C}, abstractNote = {Skin reactions associated with radiation therapy require frequent nursing assessment and intervention. Look at the question again, impaired skin integrity, what would you see IF the skin was impaired after surgical incision? Decision Making in Vocal Fold Paralysis: A Guide to Clinical Management The importance of skin care and assessment. Assessing risk and preventing pressure ulcers in patients with cancer. Hyperglycemia and hypoglycemia can both affect vascular health. 2021 Nov 26;13(12):4265. doi: 10.3390/nu13124265. . Impaired Skin Integrity. 1. - Area is usually over a bony prominence. Stage 2. Outcome: The bedsore will show optimal healing and development of further bedsores will be prevented. Due to decreased sensation to the lower legs and feet, the patient must keep feet protected to prevent skin injury. Checklist and Communication Tool for Patients Carers. As needed, wound will need to be dressed and cleaned. Read More Ineffective Breathing Pattern Nursing Diagnosis & Care PlanContinue. evidenced by intact skin. Buy on Amazon, Silvestri, L. A. Review medications. [Attention to the health of the skin. X-rays, bone scans, and arterial doppler with ankle brachial index may also be performed to determine and rule out underlying fractures, osteomyelitis, and peripheral vascular disease. Patients who are unable to ask for assistance to use the bathroom or are incontinent need frequent monitoring to keep skin dry and clean. Ask the patient to keep a journal to record and track his/her level of exhaustion or activity. This is done to avoid overnutrition. On the other hand, diagnosing vitamin deficiencies caused by overnutrition might be more challenging. Keywords: tells you it is, the edema and bruising the nurse can see for themselves. PDF Care Plan Impaired Skin Integrity Related Immobility The doctor may also prescribe oral antibiotic drugs in patients who have a lot of impetigo sores. - Lippincott 2012-09-26 The new edition of Nursing Care Planning Made Incredibly Easy is the resource every student needs to master the art of care planning, including concept mapping. Desired Outcomes: The patient will exhibit intact skin or tissues with absent excoriation. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. Experts (e.g., nutritionists) can use nitrogen balance to measure the patients nutritional state. Risk for infection. It will also help in the regular assessment in the progress of nursing care. Exposure to skin surface irritants may Identifying and addressing the underlying problems. Updated: February 4, 2021. Assess the patients extent of immobility.Understanding the patients functional mobility and level of dependence can help plan interventions and offer resources. Physiotherapists can help assess mobility and advise on positioning and mobility aids. Evidenced by bilateral swelling of the legs and feet and a small cut on the left ankle. Objectives: The objective was to summarize the . Risk for Infection Nursing Diagnosis & Care Plan, Ineffective Tissue Perfusion Nursing Diagnosis & Care Plan, Deficient Fluid Volume Nursing Diagnosis & Care Plan, Activity Intolerance Nursing Diagnosis & Care Plan, https://www.ncbi.nlm.nih.gov/books/NBK2650/table/ch12.t2/, https://www.woundsource.com/blog/understanding-braden-scale-focus-sensory-perception-part-1, https://www.in.gov/health/files/Braden_Scale.pdf, Ineffective Breathing Pattern r/t deep, fast breathing as a compensatory mechanism of metabolic acidosis, Deficient Fluid Volume r/t increased urination and vomiting, Imbalanced Nutrition: Less Than Body requirements r/t bodys inability to use glucose, nausea, vomiting, Deficient Knowledge r/t new onset of diabetes mellitus, Read More DKA Nursing Diagnosis and Care PlanContinue, NANDA-I Definition: Intake of nutrients that exceeds metabolic needs Related, Read More Imbalanced Nutrition: More Than Body Requirements [Nursing Care Plan]Continue. 2022 Sep 16;10(9):e4513. Suspected Deep tissue injury: - Skin is intact; appears purple or maroon. An expert may provide the patient with specialized apparatus to assist him/her in self-feeding. As evidenced by: impaired blood flow, alveolar perfusion and gas exchange impairment, occlusion of the pulmonary artery, migration of embolus, hypoxemia, increased cardiac workload . Intact skin--an integrity not to be lost. Ensure continuous counseling and follow-up care, most notably when reaching a plateau. A common cause of shear is elevating the head of the patient's bed; the body's weight is shifted downward onto the patient's sacrum. Br J Nurs. Advise the patient to avoid walking in bare feet.The patient should wear footwear at all times. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in educating through writing for other healthcare professionals and the general public. Evidence-based nursing intervention to reduce skin integrity impairment in children with diaper dermatitis: A systematic review . Make eating and exercising a social event. 2006 Aug;22(3):178-84. doi: 10.1016/j.soncn.2006.04.002. On the other hand, Marasmus is a disorder caused by a severe calorie deficit resulting in wasting and considerable fat and muscle mass loss. Provide supplementation of zinc, iron, iodine, and other food supplements. Anything that affects metabolic and cardiopulmonary processes also increases risk for infection so if she's got altered circulation, altered respirations, altered nutrition status, immunocompromised, etc you could relate these to the risk for infection as well. Screening and Physical Examination. Although obesity does not affect the skin's capacity to synthesize vitamin D, greater amounts of subcutaneous fat sequester more of the vitamin and alter its release into the circulation. Consequently, they may not consume enough nutrients to meet the bodys needs. Assess the cause of immobility.Causes of impaired mobility can be physical, psychological, and motivational. Her nursing career has led her through many different specialties including inpatient acute care, hospice, home health, case management, travel nursing, and telehealth, but her passion lies in educating through writing for other healthcare professionals and the general public. The patients social support will be crucial in helping him, or her implement modifications to reduce exhaustion. Pressure areas must be treated with white wool or sheepskin and examined with a long-handled metal spatula to detect any signs of redness, heat, or swelling. Radiated skin becomes thin and friable, may have less blood supply, and is at higher risk for breakdown. She received her RN license in 1997. b. Thanks! Tests performed that can diagnose and manage diabetic foot ulcers include fasting blood sugar, complete metabolic panel, erythrocyte sedimentation rate, glycated hemoglobin levels, and C-reactive protein. Similarly, overnutrition can be combated in large part through regular physical activity. Evidenced by the presence of a stage 2 pressure ulcer on the sacrum. Encourage physical activity for over-nourished individuals. Physical Assessment 85 years old (S) Perform skin assessments. Heavy alcohol consumption. Additionally, the dietician can determine the patients daily dietary needs. This is followed by the application of the prescribed antibiotic cream or ointment directly to the affected areas. For undernourished individuals, enhance the flavor of food by adding seasonings (if not contraindicated). Vitamin A deficiency is associated with dry eyes and an increased risk of infection. Assess patient's nutritional status, including weight, weight loss, and serum albumin levels. Assist him/her in employing techniques to prevent vomiting. PDF Nursing Care Plan For Impaired Skin Integrity Any break in the skin or other compromise in the bodys first line of defense can lead to pathogens possible entrance into the body. Anna Curran. Risk Factors: Indwelling urinary catheter, IV, hospital admission. She found a passion in the ER and has stayed in this department for 30 years. Assess the vital signs of the patient. Lots of older, experienced nurses that I work with don't really care too much about pain and it bothers me. A prosthetist is trained to work with those with disabilities and instruct on the wear and use of the prosthetic for optimal mobility. Nursing Diagnosis: Impaired Skin Integrity related to infection of the skin secondary to impetigo, as evidenced by red sores around the area of the nose and mouth, discharge from the sores for a couple of days, development of yellowish-brown crust, mild itching, pain and soreness. Deficiencies in nutrient absorption. Monitor and maintain a normal blood sugar level. Use less pressure and massage the skin lightly, especially around the bony prominences.