A skin nursing diagnosis is a clinical judgment made by a nurse about a patient's skin health. This diagnosis is based on the patient's skin condition, as well as their physical and emotional symptoms. A skin nursing diagnosis is used to develop a plan of care that will help the patient manage their skin condition and improve their overall health and well-being.
There are several different types of skin nursing diagnoses, including:
Impaired skin integrity: This diagnosis is made when the patient's skin is damaged or compromised in some way. This could be due to a variety of factors, such as pressure ulcers, wounds, burns, or infections.
Risk for impaired skin integrity: This diagnosis is made when the patient is at risk for developing skin damage or impairment. Factors that may increase the risk for impaired skin integrity include malnutrition, incontinence, and immobility.
Ineffective tissue perfusion: This diagnosis is made when the patient has inadequate blood flow to the skin, leading to tissue damage and impaired healing. This could be due to a variety of factors, such as poor circulation, underlying medical conditions, or the use of certain medications.
Risk for ineffective tissue perfusion: This diagnosis is made when the patient is at risk for developing inadequate blood flow to the skin. Factors that may increase the risk for ineffective tissue perfusion include dehydration, malnutrition, and immobility.
To develop a plan of care for a patient with a skin nursing diagnosis, the nurse must assess the patient's overall health and medical history, as well as their skin condition and symptoms. The nurse may also consult with other healthcare professionals, such as dermatologists or wound care specialists, to determine the most appropriate course of treatment.
Treatment options may include medications, dressings, wound care, and other therapies to promote healing and prevent further skin damage. The nurse may also provide education to the patient and their caregivers about how to properly care for the skin and prevent further skin issues.
Overall, a skin nursing diagnosis is an important aspect of patient care and helps to ensure that patients receive the care they need to manage their skin health and improve their overall health and well-being.
Impaired Skin Integrity
Wound care essentials: Practice principles. Definition and Risk factors Pediculosis. Create extensive images of the affected area with a cross-section view to check for deep tissue abscesses and organ involvement. Educate the patient on the importance of managing these chronic conditions. Educating and assisting the patient with the proper use of assistive devices. Observe for any signs and symptoms of increased pain, including guarding, flaring, or rubbing the skin.
Administer antibiotics as ordered. A deep second-degree burn indicates destruction of the epidermis and dermis, leaving only the epidermal skin appendages within the hair follicles. Lab and Diagnostic work shows: WBC 22, Blood Sugar 126. Because cancer is a cellular disease, it can arise from any body tissue, with manifestations that result from failure to control the proliferation and maturation of cells. It is easier to enlist participation when patient is aware of the possibilities that exist for recovery. Administer analgesics, anti-inflammatories, and antibiotics as ordered.
The patient needs proper knowledge of their condition to prevent impaired tissue integrity. This will help the nurse determine if the patient can tolerate solid food or will be needing alternative feeding and food preparation. Finally, defining characteristics are signs and symptoms that allow for applying a specific diagnostic label. Journal of enterostomal therapy, 17 5 , 193. This includes advising individuals who have peripheral vascular disease PVD to notice if their feet feel cold or numb, are unusually pale or cool to touch, if they have a slow capillary refill observable via pulse oximetry, or are swollen; they would then need to report this information to their physician. My care plan book has almost 20 nursing diagnoses, and I am unsure which ones to pick. Incorporate ADLs with physical therapy, hydrotherapy, and nursing care.
The patient needs to be isolated ideally for 7 to 10 days after starting treatment. Creases on sheets can cause pressure on the skin. If skin is redden or swollen, then the area must be massaged every 2 hours to help stimulate blood flow. Record leg ulcer assessment data according to standardized protocol; this includes the site of ulceration, size and number of ulcers, presence or absence of fluctuance, and color, odour and amount of drainage from ulcerations. Hydration promotes adequate skin perfusion and improves circulation. Stool may contain enzymes that cause skin breakdown. Advances in wound care, 1 5 , 189-193.
Nursing Diagnosis & Interventions for Impaired Skin Integrity
These drugs reduce inflammation and promote healing of the skin. This will be baseline data to determine the progress of the treatment plan. Check every two 2 hours for proper placement of footboards, restraints, Mechanical damage to skin and tissues pressure, friction, or shear is often associated with external devices. Compression stockings can prevent fluid build-up in the legs and ankles and improve circulation. There are more than 150 different types of cancer, including Nursing Care Plans Nurses have a huge set of responsibilities for handling a patient with cancer. It is important to maintain the cleanliness of the affected areas by washing with mild soap and water. When the bacteria enter the body, the white blood cells fight and create a collection of pus containing the bacteria, white blood cells, and dead tissue causing the abscess and death of nearby tissues.
Which Nursing Intervention Should Be Applied to a Client With a Nursing Diagnosis of Risk for Skin Integrity Impairment Related to Immobility? To preserve integrity to the rest of the skin. Administer analgesics, anti-inflammatories, and antibiotics as ordered. Edema is characterized by excess fluid accumulating in the skin and surrounding tissues. Anti-inflammatory to decrease swelling. For instance, skin integrity breakdown could occur in a patient with limited mobility.
Prevents progressively tightening scar tissue and contractures; enhances maintenance of muscle and joint functioning and reduces loss of calcium from the bone. Moisture may contribute to skin maceration. Sufficient hydration and nutrition help maintain Clean, dry, and moisturize skin, particularly bony prominences, twice daily or as indicated by incontinence or sweating. A complete medical history including past and present health conditions or infections and substance abuse must be disclosed because intravenous drug use has high rates of reported abscess cases. If powder is desirable, use medical-grade cornstarch; avoid talc.
Palpate the neck and massage the sides of the neck before feeding. Clean or assist patient in cleaning himself after opening bowels due to the location of bedsore, it can easily be reached by stool when bowels are opened. Increase tissue perfusion by massaging around affected area. Clean it with mild soap and water and keep the dressing clean. Communicate with a wound, ostomy, and continence nurse WOCN. Supportive measures and strict sterile technique should be implemented to minimize infection. This is the term used for a cluster of furuncles.
Impaired Skin Integrity Nursing Diagnosis and 5 Best Care Plans
Because NANDA-I is an international organization, the approved nursing diagnoses are the same. Nursing Care Plan 2 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 Intervention Rationale Educate on diabetic neuropathy and the importance of daily skin checks When blood glucose is uncontrolled it can injure the nerves, most often in the legs and feet causing diabetic neuropathy. If more moisturizing is required than a lotion can provide, a cream is recommended. The pressure needed to close capillaries is around 32 mm Hg; any pressure above 32 mm Hg leads to ischemia. These findings will give information on the extent of the impaired tissue integrity or injury.
I have chosen impaired skin integrity as one. Mild edema will usually not require any interventions, as the swelling will subside on its own. Preventing and treating edema requires lifestyle modifications as well as strict treatment adherence. The patient who scratches the skin to alleviate extreme itching may open skin lesions and increase the 9. Assess laboratory studies for any abnormalities.
