NANDA-NursingPlan Area 11 Safety/Defense

NANDA-Nursing Plan 00046 Impaired skin integrity

Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.


Area 11 Safety/Protection No danger, physical injury or damage to the immune system, loss prevention, guarantee of safety and security
Category 2 Bodily injury Bodily harm or injury

00046 Impaired skin integrity

Nursing Diagnosis: Impaired skin integrity
Definition: Altered epidermis and/or dermis

Please refer to the following articles as well.

1. Indications for Nursing Diagnosis Impaired skin integrity

・Pressure ulcer evaluation 1: NPUAP classification (see ✩1 below for NPUAP classification)
・Stage I (abnormalities on the epidermis)
・Stage II (ulceration extending to the dermis)
*Since the definition of skin integration disorder is “a condition in which both or one of the epidermis and dermis is altered,” it corresponds to stages I and II of the NPUAP classification. However, it is actually designed for pressure ulcers deeper than the subcutaneous tissue.
・Pressure ulcer evaluation 2: DESIGN-R (See ✩2 below for DESIGN-R)
・DESIGN-R d2
・History of pressure ulcers
・Trauma, burns (thermal, cold, chemical)
・Radiation therapy (cancer treatment)
·edema
・Epidermal infection
・Drug eruption, skin eruption
・Skin troubles due to stoma (urostomy, colostomy)

✩ 1。 NPUAP classification (pressure ulcer definition and stage classification)

Excerpt from Japanese Society of Pressure Ulcers: Prevention & Quick Reference Guide for Pressure Ulcers (1st Edition 2004, 2nd Edition 2014)

https://www.epuap.org/wp-content/uploads/2016/09/japan_quickreferenceguide_sep2016.pdf

*NPUAP is a pressure ulcer depth classification. Please search.

✩ 2 。DESIGN-R 2020

*Design-R is a scale for evaluating pressure ulcers from several perspectives.
It can also be used over time to assess progress in healing.
Please search for it.

Quoted from the Japanese Society of Pressure Ulcers
http://www.jspu.org/jpn/member/pdf/design-r2020_doc.pdf

In the 2020 revision, the item “3C” has been added to I (infection/inflammation). “3C: Suspicion of critical colonization” refers to “at first glance, the affected area appears reddish and blood flow is maintained, but the flesh does not grow and epithelialization does not progress”. In this condition, epithelialization does not progress because skin regeneration is inhibited by infection. The affected area, which is suspected to be critically colonized, has a bacterial membrane called a biofilm, and is characterized by being slimy and shiny as a whole.
“DTI” is also added in the D (depth) area. “DTI: deep injury pressure ulcer” refers to a pressure ulcer in which even if the epidermis is slightly damaged, it is soft and inelastic when touched from above, and the damage may spread internally. For example, there is a defect in the epidermis of 1 cm in size, which at first glance looks like a small pressure ulcer, but when a dermatologist examines it, the subcutaneous tissue and muscles behind it are also damaged. . DTI is a more serious condition than it appears.    

                              

2. aim setting

Goal setting by linkage (listed in the second half of the NOC)
* “Linkage” has the role of connecting “NANDA”, “NIC” and “NOC” (link means “connection”).

1) Linkage achievements

・Tissue integrity: skin and mucosa (1101)
(Definition: Normal physiological function without skin and mucosal tissues)
・Nutritional status: intake of nutrients (1009)
(Definition: intake of nutrients to meet metabolic needs)
・Nutritional status: biochemical test value (1005)
(Definition: biochemical indicators of body fluid composition and nutritional status)
・Sensory Function: Tactile (2400)
(Definition: ability to correctly perceive skin irritation)
・Circulatory dynamics (0401)
(Definition: the unidirectional flow of blood through the great vessels of the systemic and pulmonary circulations at normal perfusion pressure and without stagnation)
・Physical aging (0113)
(Definition: normal physiological changes that occur with natural aging)
・ Posture change: Self-power (0203)
(Definition: Movement to change position with or without assistive devices)
・ Body fluid status (0602)
(Definition: Adequate amount of intracellular and extracellular fluid in the body)
・Volume overload severity (0603)
(Definition: severity of excess intracellular and extracellular fluid)
– Urinary control (0502)
(Definition: control of urine output from the bladder)
・Defecation control (0500)
(Definition: control of defecation process)
・Self-care for ostomy (artificial anus, artificial bladder) (1615)
(Definition: Behavior of an individual to continuously manage an ostomy for elimination)
・Severity of infection (0703)
(Definition: severity of signs and symptoms of infection)

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do ○○”,
For example, “The patient will be able to do ○○.”
・Keeps the skin clean and prevents infection.
・If you have any skin abnormalities (redness, swelling, pain, rash, heat sensation), you can tell the medical staff.
・Do not use dirty urine pads and replace them after excretion.
・You can take meals that are nutritionally balanced. If you have no appetite, you can consult a doctor.
・Incorporate moderate exercise into your life.
・When sleeping, you can change your position from time to time so that you do not stay in the same position for a long time.

※The goals of the nurse’s actions are as follows.
・Promote the healing of pressure ulcers and skin problems by using decompression equipment, regular position changes, and appropriate positioning.
・Promote the healing of pressure ulcers and skin troubles by adjusting the nutritional balance.
・Collaborate with the skin excretion care nurse to implement pressure ulcer treatment according to the state of the pressure ulcer/skin trouble.
・Properly manage the stoma and eliminate skin problems.

3. nursing plan


1 >> Observation plan 《OP》

・Automatic movement (supine, lateral, standing, sitting)
・History of pressure ulcers
・Skin temperature ・Skin sensation ・Skin elasticity ・Skin moisture content ・Skin thickness
・Body hair growth
・Abnormal pigmentation
・Skin lesions ・Mucous membrane lesions ・Scar tissue
・Skin cancer
・Skin redness and heat after radiation therapy
・Skin peeling/skin desquamation
・ Pale skin
・Skin infection
・Rupture of epithelium ・Rupture of subcutaneous tissue
・Decubitus area
・The size of the pressure ulcer
・Pressure ulcer infection: exudate, foul odor, pus-like discharge, biofilm
・Depth of pressure ulcer
・Pressure ulcer: color of granulation
・Necrotic tissue, sensation
・Bleeding of pressure ulcer
・Pressure ulcer treatment details
・Calorie intake ・Protein intake ・Fat intake ・Carbohydrate intake ・Fiber intake
・Vitamin intake ・Mineral intake
・Iron intake
・Sodium intake ・Calcium intake
・Water intake
・Serum albumin level ・Serum prealbumin level ・Serum creatinine level ・Hematocrit value
・Hemoglobin level ・Serum transferrin level
・Discrimination of sharp stimulus ・Discrimination of dull stimulus ・Discrimination between two points
・Identification of vibration
・Temperature identification
・Pressure identification
・Dysparesthesia/Loss of sensation
・numbness
・Blood pressure ・Pulse pressure ・Average blood pressure ・Central venous pressure ・Distention of the jugular vein ・Syncope
・PaO2・PaCO2
・Oxygen saturation
・Urine volume
・Capillary filling time
・Vascular murmur ・Heart murmur
・Peripheral edema
・Ascites ・Fatigue ・Weight gain
・Skin temperature drop ・Sensory abnormality
・Pilt edema
・Lower leg ulcers
・ Decrease in body fluid volume ・ Decrease in cells ・ Elasticity of skin
・Bone density
・Muscular strength
・Cardiac output/blood pressure
・Lung capacity
・Basal metabolic rate
・Fat distribution pattern
・Joint range of motion
・diarrhea
・Periorbital edema ・Limb edema ・Sacral edema
・Ascites ・Weight gain ・Generalized edema
・Pulmonary murmurs (bubbles)
〈Urination control〉
→ Skin maceration/skin disorder due to urinary incontinence
・Urinary pattern ・Urinary urge ・Urinary incontinence
・Urine volume
・Feeling of residual urine ・Residual urine
・Wearing diapers
・Water intake
・Defecation pattern
・Stool condition (diarrhea)
・Intention to defecate
・Water intake
・Tube feeding
・Lactose intolerance (inappropriate for tube feeding)
・Fecal incontinence ・Wearing diapers
・Use of antibiotics (risk of diarrhea due to bacterial replacement)
・Use of anticancer drugs (molecular target drugs, immune checkpoint inhibitors, irinotecan, etc.)
・Color of the stoma ・Skin condition around the stoma
・Excretion (stool) from the stoma fistula: color, amount, properties, presence or absence of exhaust gas
・Color, amount, floating matter, turbidity, and odor of excrement (urine) from the stoma fistula
・How to change the stoma

2 >> Action plan 《TP》

・The content and form of meals should be devised so that the necessary amount of food intake can be secured.
・In the case of nutritional deficiencies, supplementary foods should be considered.
・Perform appropriate positioning. (especially avoid compressing bony prominences)
・Change positions regularly. If it is possible to change the body position on its own, talk to it regularly.
・If you are sitting in a wheelchair for a long time, use a pressure-resistant cushion and periodically call out to relieve the pressure.
・If you are bedridden, consider using an air mattress.
・Use the dehumidification mode and automatic intercourse mode of the air mattress.
・Measure body weight regularly.
・If there is edema, perform drainage and massage.
・If you cannot make it to the toilet in time and are incontinent, consider using a urinal or portable toilet.
・When wearing diapers, clean the pubic area.
・If the baby has diarrhea, change diapers frequently.
・Consult a doctor if you have diarrhea due to starting tube feeding. (Consider changing nutritional supplements)
・Consult a doctor if you have diarrhea due to the start of antibiotics. (Consider intestinal and antidiarrheal agents)
・Consult a doctor if diarrhea occurs due to anticancer drugs. (Antidiarrheal agents may be considered, or fluid replacement may be considered in the case of anticancer drugs for which antidiarrheal agents cannot be used.)
• Keep warm if obliteration circulation is not maintained. (hot water bottle, hanging, room temperature)
・If there is edema, pay attention to postural changes. (Avoid skin breakdown)
・Affix a film dressing to reinforce skin peeling and subcutaneous bleeding due to fragility of the skin. Water-repellent petroleum jelly is applied to areas where it is difficult to apply the film to protect the subcutaneous tissue from irritation (make it act like an epithelium).
・Understand the urination pattern and defecation pattern, and guide the patient to the toilet before urinary or fecal incontinence occurs.
・Periodically dispose of excrement in the stoma.
・Replace the stoma.
・Defecation management. (warm compresses, abdominal massage, laxatives, etc.)
・If the stoma does not fit, cooperate with the skin excretion care nurse.
・Cooling (not frozen but refrigerated) for dermatitis after radiation therapy.
・For dermatitis after radiation therapy, wash with foam without rubbing.
Use a moisturizer (heparin cream) for dermatitis after radiation therapy.

3 >> Education plan  《EP》

・If you feel the urge to urinate or defecate, tell the patient to call the nurse.
・Explain that if you incontinence, don’t be shy and call the nurse. (Explain the need for a nurse call if long-term adhesion of waste causes skin problems.)
・Teach them to eat a well-balanced diet.
・Instruct the patient not to stay in the same position for a long time and to release the pressure occasionally.
・Explain to let them know if they have numbness, paresthesia, or swelling.
・Explain that if diarrhea occurs due to the use of antibiotics or anticancer drugs, the patient should be notified.
・Explain not to hit the swollen part.
・Explain the function and purpose of the stoma, and precautions for its management.
・Explain the procedure for exchanging a stoma.
・Explain not to rub dermatitis after radiation therapy.
・Explain how to wash and manage the body after radiation therapy.
・Other points to consider after radiotherapy will be explained.

References

T. Heather Hardman Shigemi Kamitsuru. (2016). NANDA-I Nursing Diagnosis Definition and Classification 2015-2017. Igaku Shoin.
Okaniwa, Yutaka. (2012). Review book for nurses and nursing students. Medic Media Co., Ltd.
Yutaka Okaniwa. (2019.3). Year Note 2020. Medic Media Co., Ltd.
Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan K.K.
Toru Yamaguchi, Mitsuo Kitahara, Tsuguya Fukui. (2012). Today’s treatment guidelines. Yumiko Ohashi, Hajime Yoshino, Naoki Aikawa, Sumi Sugawara. (2008).

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