NANDA-NursingPlan Area 11 Safety/Defense

NANDA-Nursing Plan 00044 Impaired tissue 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/Defense
Category 2 Bodily injury Bodily harm or injury

00044 Impaired tissue integrity

Nursing Diagnosis: Impaired tissue integrity
Definition: Conditions involving damage to mucous membranes, cornea, integumentary system, fascia, muscles, tendons, cartilage, joint capsules, and ligaments.

Looking at the definition of tissue integrity disorder, “a condition in which there is damage to the mucous membrane, cornea, integumentary system, fascia, muscle, tendon, cartilage, joint capsule, or ligament”, it encompasses damage to many organs. It is usually difficult to imagine that the damage of the two can occur at the same time. Possible causes include fire burns, high-energy trauma (traffic injuries, falls from height, plane crashes), and natural disasters (self, tsunamis, lightning, etc.).

Please refer to the plan below

1. Indications for the Nursing Diagnosis Impaired tissue integrity


・Pressure ulcer
・Burns
・Irritation to the epidermis (capsaicin, patches)
・Drugs administered (aphtha due to anticancer drugs, hair loss) (appearance of drug eruption)
・Intestinal bacterial infection (pseudomembranous enteritis due to Clostridium difficile)
・Wearing diapers (infant, elderly)
・Position change not possible due to lack of knowledge of caregiver
・Rash or mucosal edema due to latex allergy or food allergy
・Tissue damage due to pulling medical indwelling objects, skin troubles when fixing, damage due to self-extraction
(tracheal tube, drain, CV, DIV, indwelling bladder catheter, gastrostomy, bladder fistula)
・Keratitis


・Osteoarthritis of the knee ・Osteoarthritis of the hip ・Osteoarthritis of the elbow
·fracture
– ligament tear

〈Something〉
・Poor nutritional status (influence on skin and mucous membrane regeneration such as lack of vitamins)
・Undernutrition
·obesity
・Electrolyte and water abnormalities
・Insufficient circulation to the epidermal system, peripheral neuropathy
·Diabetes mellitus

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)

・Wound healing: primary healing (1102)
(Definition: extent of cell and tissue regeneration after wound closure)

・Recovery from burns (1107)
(Definition: degree of psychosomatic treatment associated with severe burns)

・Nutritional status (1004)
(Definition: the state in which nutrients are ingested and absorbed to meet metabolic needs)

Ostomy self-care (1615)
(Definition: Behavior of an individual to continuously manage an ostomy for elimination)

*An ostomy is an artificial excretory tract such as an artificial anus or an artificial bladder.

・Sensory Function: Tactile (2400)
(Definition: ability to correctly perceive skin irritation)

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 ○○.”

・If you develop any abnormalities in the course of burns, consult a medical professional.

・Appropriate management of the stoma is possible.

・If you notice any abnormalities during cast fixation, you can consult a medical practitioner.

・If you have pain, heat, swelling, or redness on your skin, muscles, or bones, consult a doctor.

*Nurse goals include:

・Promote tissue healing by keeping the skin clean, preventing infection, and maintaining appropriate care.

・Properly manage the stoma to prevent new infections and skin problems.

・In the case of burns, life support is provided in accordance with the healing process to promote tissue healing.

3. nursing plan

1) Observation Plan 《OP》

・Skin temperature
・sense
・Turgol reaction
・Skin integrity
・Abnormal pigmentation
・Skin lesions
・Mucous membrane lesions
・Scar tissue
・Skin peeling
・Erythema
・ Pale
・Necrosis
・Induration
・Sensory stimulation of the skin (sharp stimulation, dull stimulation, temperature, vibration, pressure, numbness, paralysis without feeling)

〈Wound healing: primary fusion〉
・Skin junction
・Welding of wound periphery
・Scar formation
– Purulent discharge
– Serous drainage
・Blood drainage
・Drainage (amount, color, properties)
・Redness of the surrounding skin
・Contusion of surrounding skin
・Edema around the wound
・Rise in skin temperature
・Foul smell of the wound

〈Recovery from burns〉
・Tissue granulation
・Tissue perfusion of the burn site
・Healing rate
・Stabilize body temperature
・Electrolyte stability
・Body fluid balance
・Self-care ability
・Movement of limb joints
・Walking state
・Psychological reaction to changes in appearance (acceptance process)
・Psychological adaptation to physical changes
·pain
・Analgesics (drugs, frequency of use)
・Oxygen saturation
・Difficulty breathing
·Weight loss
・Wound infection (bad odor, drainage, redness, swelling, heat sensation, pain)
・blister
・Edema at the burn site
・Tissue necrosis
・Generalized edema
・Gastrointestinal complications
・Decreased urine volume
・The need for skin grafting at the burn site

・Nutrition intake, food form
・Gastrointestinal diseases
・Food intake
・Water intake
・energy
・BMI
* BMI calculation method: weight (kg) ÷ height (m) x height (m)
* BMI normal: 18.5 abnormal less than 25 (less than 18.5 is underweight) (over 25 is obese)
・Hydration ・Blood data
・Alb (standard value: 3.8 to 5.3 g/dl)
・TP (reference value: 6.7-8.3g/dl), Hb,
・TG triglyceride (reference value: 34-149mg/dl)
・HDL good cholesterol (standard value: 46-96mg/dl)
・Hb hemoglobin (standard value: 13-17 for men, 11-15 g/dl for women)


・Skin condition around the stoma
・Normal amount of waste in the stoma
・Meal contents
·amount of water
・ Exhaust gas (in the case of colostomy)

2) Action plan 《TP》

・When exchanging the stoma, use a remover while exchanging the stoma so as not to peel off the skin. Also, use a skin barrier before application to prevent skin damage.
・For burns, the treatment plan differs depending on the severity.
・If there is dyspnea due to burns (after airway burns), carefully observe the respiratory condition and immediately report any abnormalities to the leader and the doctor.
・In the case of severe burns, systemic management is necessary. Observe for shock due to loss of body fluids, infection and circulatory failure due to epidermal defects and functional abnormalities, and report any abnormalities to the leader and doctor.
・If there is a wound after surgery or trauma, keep the wound clean and follow the doctor’s instructions to perform gauze replacement and Nanko treatment.
・If the amount of food intake is low, try to increase the amount of food intake by devising food forms and adding supplementary foods.
Use pain relievers if you have pain.
・Organize routes for intravenous drips and oxygen, etc., to prevent self-extraction and falls.

3) Education plan 《EP》

・Instruct the patient to call the nurse immediately if there is an abnormality.
・Explain that analgesics can be used if there is pain, and encourage the patient to press the nurse call without being patient.
・Explain that the wound should be touched with clean hands (if showering is permitted).
・Instruct the patient not to touch the wound that has not yet healed (only the top of the bandage can be touched).
・Explain the stoma replacement procedure and management method. In addition, in the event of an abnormality, we will explain that you should visit a hospital and receive appropriate treatment.
• Explain the importance of nutrition for tissue healing.

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.
Yamaguchi Toru, Kitahara Mitsuo, Fukui Tsuguya. (2012). Today’s treatment guidelines.
Toyoaki Yamauchi. (Date unknown). Physical Assessment Guidebook. Igaku Shoin.
Yumiko Ohashi, Hajime Yoshino, Naoki Aikawa, Sumi Sugawara. (2008). Nursing Learning Dictionary (3rd Edition). Gakken Co., Ltd. (Gakken).

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