Impaired Skin Integrity
Related Factors
External (environmental)
- Chemicals.
- Humidity.
- Hyperthermia.
- Hypothermia.
- Mechanical factors (cut, depressed, due to restrain).
- Drug.
- Skin moisture.
- Physical immobilization.
- Radiation.
Internal (somatic)
- Fluid status changes.
- Pigmentation changes.
- Turgor changes.
- Developments factors.
- Nutritional imbalance.
- Immunological deficit.
- Circulatory disorders.
- Impaired metabolic status.
- Impaired sensation.
- Herniated discs.
Developments factors
- Extreme age young or old
Defining Characteristics
Objective
- Damage to the skin layer.
- Damage to the skin surface.
- Invasion of the body structure.
Results & NOC
NOC:
- The local allergic response; the severity of the local immune hypersensitivity to certain environmental antigens.
- Access hemodynamics; functioning dialysis access area.
- Tissue integrity : skin and mucous membranes; structural integrity and normal physiological function of the skin and mucous membranes.
- Wound healing: primary; the level of cell and tissue regeneration after closing deliberate.
- Healing wounds: secondary; level cell regeneration and tissue in an open wound.
NIC
Assessment
- Assess the function of tools, such as a drop in pressure.
- Treatment incision area (NIC): inspection redness, swelling or signs of dehiscence or evisceration at the incision area.
- Wound care (NIC): wound inspection at every change the bandage.
- Assess injuries to these characteristics:
- location, area and depth.
- the existence and character of exudate, including viscosity, color and smell.
- presence or absence of granulation or epithelialization.
- the presence or absence of necrotic tissue. describe the color, smell and the number.
- presence or absence of signs of local wound infection.
- presence or absence expansion cuts into the tissue under the skin and sinus tract formation.
Counseling for Patients and Families
- Teach surgical incision wound care, including signs and symptoms of infection, how to keep the incision remain dry while bathing, and reduce the emphasis on the incision area.
Collaborative Activities
- Consult a nutritionist about foods high in protein, minerals, calories and vitamins.
- Consult to the doctor about the implementation of the provision of food and enteral or parenteral nutrition to improve wound healing potential.
- Refer to the nurse for treatment enterostoma to get help in the assessment, discovery degrees wounds and wound care documentation or skin damage.
- Wound care (NIC): use a TENS unit (Transcutaneous electrical nerve stimulation) to enhance the wound healing process, if necessary.
Other Activities
- Evaluation of treatment or dressing that may include hydrocolloid bandage, hydrophilic bandage, absorgen bandage and so on.
- Perform wound or skin care routine such as:
- change and adjust the position of the patient often
- defend the tissue around the drainage and free from excessive humidity
- protect patients from contaminated feces or urine
- protect patients from the excretion of other injuries and drain tube in the wound
- cleaned and bandaged the wound area using the principle of sterile surgical or medical aseptic following actions, if necessary:
- use disposable gloves
- wipe the incision area from the clean area to dirty use a gauze or one on each side of the gauze swabs
- clean the area around the seams using a sterile swab
- clean the drainage around the tip, moving in a circular motion from the center out
- paparat use antiseptic, according to the program
- dressing bandage at suitable intervals or let the wound remains open according to program
- wound care (NIC):
- remove the bandage and plaster
- wash with normal saline or nontoxic cleaners, if necessary
- place the injured area in a special bath, if necessary
- do the treatment of skin ulcers, if necessary
- set position to prevent pressure on the wound, if necessary
- do maintenance on the IV infusion area, hickman lines or a central venous line, if necessary
- do massage in the area around the wound to stimulate circulation
Home Care
- above measures appropriately applied to home care
- do case management, or refer to the treatment of wound care experts or ostomy care if necessary
- surveillance skin (NIC): encourage family members and caregivers to observe signs of skin damage, if necessary
- wound care (NIC): teaching wound care procedures to patients or family members