Altered epidermis and/or dermis: Invasion of body structures, destruction of skin layers (dermis), and disruption of skin surface (epidermis).
Related Factors:
- External:
Hyperthermia, hypothermia, chemical substance, mechanical factors (e.g. friction, shearing forces, pressure, restraint), physical immobilization, humidity, extremes in age, moisture, radiation, medications - Internal:
Altered metabolic state, altered nutritional state (e.g. obesity, emaciation), altered circulation, altered sensation, altered pigmentation, skeletal prominence, developmental factors, immunological deficit, alterations in skin turgor (change in elasticity), altered fluid status.
Suggested Nursing Outcomes
- Tissue Integrity: Skin and Mucous Membranes
- Wound Healing: Primary Intention
- Wound Healing: Secondary Intention
- Regains integrity of skin surface
- Reports any altered sensation or pain at site of skin impairment
- Demonstrates understanding of plan to heal skin and prevent reinjury
- Describes measures to protect and heal the skin and to care for any skin lesion
- Incision Site Care
- Pressure Ulcer Care
- Skin Care: Topical Treatments
- Skin Surveillance Wound Care