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Nursing Diagnosis Definition
The nursing diagnosis for Deterioration of Cutaneous Integrity is defined as "a disruption in the normal structure and function of the skin, characterized by breakdown, ulceration, and possible infection." This diagnosis is applicable when there is a compromise in the integrity of the skin, leading to structural damage and functional impairment.
Defining Characteristics
Subjective:
- Patient reports pain or discomfort in the affected area: Subjective complaint indicating discomfort or pain in the region with compromised skin integrity.
- Patient reports difficulty healing: Subjective observation of challenges in the healing process.
- Patient reports a change in the appearance of the affected area (e.g. redness, swelling, ulceration): Subjective indication of visual alterations in the affected skin area.
Objective:
- Breakdown or ulceration of the skin is observed: Objective assessment confirming the presence of skin breakdown or ulceration.
- Patient has difficulty healing: Objective observation of impaired healing in the affected area.
- Patient has a change in the appearance of the affected area (e.g. redness, swelling, ulceration): Objective assessment of visual changes in the affected skin area.
- Inadequate hygiene: Poor personal cleanliness contributing to skin issues.
- Poor nutrition: Inadequate dietary intake affecting skin health and healing.
- Certain medical conditions (e.g. diabetes, venous insufficiency): Underlying health issues impacting skin integrity.
- Certain medications (e.g. corticosteroids, chemotherapy): Pharmaceutical agents affecting skin structure and function.
- Pressure ulcers: Prolonged pressure on the skin leading to breakdown.
Risk Population
- Older adults: Increased susceptibility to compromised skin integrity due to age-related factors.
- Individuals with chronic medical conditions: Those with long-term health issues may be at higher risk.
- Individuals who are bedridden or have limited mobility: Reduced mobility contributing to skin problems.
- Individuals who are receiving certain types of medical treatment (e.g. corticosteroids, chemotherapy): Medical interventions affecting skin health.
Associated Problems
- Infection: Secondary complication resulting from compromised skin integrity.
- Pain: Discomfort associated with the affected skin area.
- Difficulty healing: Impaired wound healing process.
- Malnutrition: Poor nutritional status impacting skin health.
- Dehydration: Reduced fluid levels affecting skin hydration and health.
Suggestions for Use
- Assess the patient's hygiene and provide instruction as needed: Evaluate and guide the patient on proper personal hygiene practices.
- Assess the patient's nutrition and provide nutrition education as needed: Evaluate dietary habits and offer nutritional guidance to support skin health.
- Assist the patient in managing any underlying medical conditions (e.g. diabetes, venous insufficiency): Collaborate with healthcare providers to address and manage contributing medical conditions.
- Monitor the patient for signs of infection and implement appropriate interventions: Regularly assess for signs of infection and take necessary actions for prevention and management.
- Provide wound care as needed: Administer appropriate wound care to facilitate healing and prevent further deterioration.
Suggested Alternative Nursing Diagnoses
- Impaired Skin Integrity: General impairment of the skin's condition.
- Impaired Wound Healing: Specific focus on challenges in the wound healing process.
- Risk for Infection related to impaired skin integrity: Emphasizing the potential for infection due to compromised skin.
- Impaired Physical Mobility related to impaired skin integrity: Addressing mobility issues contributing to skin problems.
Usage Tips
- Consider the patient's overall health status and any underlying medical conditions when making a diagnosis: Take a comprehensive view of the patient's health for accurate diagnosis and intervention planning.
- Be specific when documenting the appearance of the affected area (e.g. redness, swelling, ulceration): Provide detailed and precise documentation of visual changes in the skin.
- Consider using additional diagnoses to address associated problems (e.g. risk for infection, impaired physical mobility): Use additional diagnoses as needed to comprehensively address patient needs.
NOC Results
- Skin Integrity: Continuous monitoring of the patient's skin condition to ensure it remains intact and functions properly.
- Wound Healing: Regular assessment of the patient's wound to verify that it is healing properly.
- Infection Control: Ongoing evaluation of the patient's infection status and implementation of interventions to prevent infection.
NIC Interventions
- Skin Care: Provide appropriate skin care to maintain the integrity of the skin, preventing further breakdown.
- Wound Care: Administer wound care as needed to promote optimal healing and prevent infection.
- Infection Control: Implement appropriate infection control measures to prevent and manage infection, ensuring overall skin health.
- Nutrition Support: Provide appropriate nutrition support to maintain skin integrity and prevent malnutrition, addressing a key factor in cutaneous health.
- Mobility Assistance: Provide assistance with mobility to prevent pressure ulcers and promote healing, addressing a contributing factor to skin deterioration.
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