NANDA-NursingPlan Area 11 Safety/Defense

NANDA-Nursing Plan 00047 Risk for 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

00047 Risk for impaired skin integrity

Nursing Diagnosis: Risk for impaired skin integrity
Definition: A condition in which the epidermis and/or dermis are susceptible to changes that can compromise health.

Thank you for always watching.
The skin integrity risk status overlaps with the pressure ulcer risk status. The Dysdermal Integrity Risk Status also deals with causes of skin problems other than pressure ulcers.

Please refer to the article below.

1. Indication of “Risk for impaired skin integrity”

*Pressure ulcer risk status and content overlap. The Dysdermal Integrity Risk Status also deals with causes of skin problems other than pressure ulcers.
・Screening: Braden scale (under 18 points for adults), Braden Q scale (under 16 points for children) See ✩ 1 below for Braden scale
・Thinness, poor nutritional status, conspicuous bony protrusions
・Obesity, arteriosclerosis
·smoking
・Wet skin (wearing diapers), incontinence
・Skin thinning (edema)
・Decreased skin elasticity (decreased Turgol reaction, dehydration) See ✩3 below for Turgol reaction
・Same position for a long time, difficult to change position on one’s own
・Intraoperative positioning and fixation, postoperative rest
・Use of sedatives, paralysis,
・After orthopedic surgery (relieving the affected limb, resting, contraindicated positions)
・Body restraint
・Wrong posture change method, positioning
・History of pressure ulcers
・Trauma, burns (thermal, cold, chemical), sutured wounds
・Radiation therapy (cancer treatment)
·edema
・Epidermal/dermal infection (cellulitis, etc.)
・Drug eruption, skin eruption
・circulatory failure
・Undernutrition

✩ 1 Braden scale

The Braden Scale is a tool used to predict the development of pressure ulcers.
Search for scales in your country.

✩ 3 Turgor reaction

Use when body fluid volume decreases such as dehydration.
Pinch the skin above the forearm or sternum and release it, and if the skin returns to its original state within 2 seconds, it is judged to be normal. It takes longer than 2 seconds, and it is called a handkerchief sign that the wrinkles of the skin are slow to return. .

2. Goal setting (linkage → goal)

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)
・Ostomy self-care (1615) *Ostomy is artificial anus and artificial bladder
(Definition: Behavior of an individual to continuously manage an ostomy for elimination)
・Drug reaction (2301)
(Definition: therapeutic effects and side effects of prescribed drugs)

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do XX”,
For example, “The patient will be able to do ○○.”

・Be able to take actions to prevent pressure ulcers, such as removing pressure regularly and changing positions.

・Able to eat nutritionally balanced meals.

・If you feel any abnormalities in your skin or sensation, you can consult a medical professional.

・You can use a clean urine pad without using a diaper or pad for a long time after urinating.

・Describe how to manage an ostomy and be able to actually manage it.

*Nurse goals include:

・Prevent the development of pressure ulcers by using decompression equipment, regular repositioning, and proper positioning.

・Nutritional balance is maintained to improve the health of the skin and musculoskeletal system (to prevent weight loss).

・Maintain the cleanliness of the skin and the circulation of the skin to prevent pressure ulcers from occurring due to skin problems.

・Properly manage the ostomy and prevent skin problems.

・Early detection of allergic reactions caused by allergens such as drugs, etc., and efforts to deal with them at an early stage.

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
・mucosal lesions
・Scar tissue
・Skin cancer
・Skin peeling/skin desquamation
・Skin pallor, peripheral cold sensation, nail bed cyanosis
・Skin pruritus, pruritus
・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 value ・Serum transferrin value
・Discrimination of sharp stimulus ・Discrimination of dull stimulus ・Discrimination between two points
・Identification of vibration
・Temperature identification
・Pressure identification
・Paresthesia ・Loss of sensation ・Numbness ・Paralysis
・Blood pressure ・Pulse pressure ・Mean blood pressure ・Central venous pressure
・PaO2・PaCO2
・Oxygen saturation
・Urine volume
・Capillary filling time ・Nail bed cyanosis ・Peripheral edema
・Vascular murmur ・heart murmur ・fainting
・Distention of the jugular vein
・Ascites/weight gain
・ paresthesia
・Pilt edema
・Lower leg ulcers
・ Decrease in body fluid volume ・ Decrease in cells ・ Elasticity of skin ・ Muscle strength
·Bone density
・Cardiac output/blood pressure
・ Bladder muscle engorgement
・Basal metabolic rate
・Fat distribution pattern
・Diarrhea, wearing diapers, incontinence
・Periorbital edema
・Edema of extremities
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
・Wearing diapers
・Water intake
・Defecation pattern ・Defecation urge
・Stool condition (diarrhea) ・Fecal incontinence
・Tube feeding
・Lactose intolerance (inappropriate for tube feeding)
・Use of antibiotics (risk of diarrhea due to bacterial replacement)
・Use of anticancer drugs (molecular target drugs, immune checkpoint inhibitors, irinotecan, etc.)
〈Ostomy self-care〉*Ostomy is artificial anus and artificial bladder
・Skin condition around the stoma
・Conditions of stool from the stoma (artificial anus): muddy, watery, color, odor
・Characteristics of urine from stoma (artificial bladder): color, turbidity, odor
・ Degree of self-care acquisition for stoma management
– Newly added drugs
・History of drug allergy/food allergy
・Allergens (bees, food, latex, metals, chemicals)
・Drug-induced anaphylaxis (mucosal edema)
・ Dyspnea
・Shock (blood pressure drop due to anaphylaxis)
・ Rash (extensive erythema and papules)
・Allergic reactions to drugs
・Rash (papules/erythema)
・ Itching
・Edema of the eyelids, pubic area, etc. (a step before anaphylaxis, which may be severe)

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)
cormorant.
・Use protective materials in areas likely to develop pressure ulcers.
・Observe the size, depth, bleeding, amount of exudate, etc. of the pressure ulcer according to DESIGN-R
・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.
・Use a stoma remover to replace the stoma gently.
・Wash with foam so as not to rub the stoma.
・Use a protective material before attaching the stoma.
・If there are wrinkles around the stoma due to changes in body shape, take measures to fill the gaps so that the excrement does not come in contact with the skin.
・If skin problems persist, consult with a certified nurse for skin and excretion care.
・When infusing a blood transfusion or a new drug, observe carefully for 15 minutes from the start.
・If you have an allergic reaction after administering the drug, stop taking the drug and report it to your doctor.
・If you have an allergic reaction, use steroids or anti-allergic drugs according to your doctor’s instructions.

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.
・Use a pamphlet to explain how to properly manage the stoma. (washing, changing, observing, eating, etc.)
・Ask the patient to let us know if there is any abnormality in the discharge from the stoma.
・If you experience any discomfort such as itching or difficulty breathing after starting the drug, please let us know immediately.

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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