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Nursing Diagnosis of Impaired Skin Integrity

Nursing Diagnosis of Impaired Skin Integrity

Nurse diagnosis of inferiority of damaged skin

Nursing Diagnosis of Impaired Skin Integrity

4. December 2019 Health Care

Violation of skin integrity refers to damage to skin tissue, e.g. subcutaneous, corneal or fleece tissue, etc. If you have difficulty moving from one place to another, you may have skin problems.

Colourless leather integrity:

The largest organ in our body is the skin, which forms a protective barrier for your body. The skin integrity diagnosis helps to develop an effective skin care plan. As we all know, the skin protects our body against all external infections that occur in case of heat and light or accidents, and so on. Skin integrity can be defined as the strength and health of the skin. A skin integrity disorder is any damage to the skin, such as B. damage to the skin as a result of an accident or incorrect skin formation resulting in skin damage. The nurse treating skin diseases must therefore be familiar with all aspects of risk management.

Patients with spinal cord problems, shearing forces, physical mobility problems, etc. are not eligible for the programme. Many other factors such as age, poor nutrition and environmental problems can also cause skin integrity problems. Overweight, disabled and crippled patients can cause injury and skin damage, increasing the risk of skin integrity impairment for people with disabilities.

To alleviate the suffering of patients, doctors or nurses sometimes offer special mattresses and equipment. Wound care tests should be taught to nurses working with skin integrity problems. Since skin problems cannot easily be examined in a single session, multiple sessions are needed to observe skin behaviour and temporary conditions. It will be useful to make an exit plan.

Factors underlying the risk of loss of skin integrity:

The following causes and factors can be used to identify problems and factors related to skin integrity.

  • Allergic to irritants such as soap, dyes, adhesives, etc.
  • Problems with the silence
  • back issues
  • Medical history or oedema related to radiation
  • Difficulties related to compensation
  • itchy skin
  • Displacement or pressure with loss of feeling
  • Mechanical reactions such as a surgical scratch on the skin, etc.
  • Ambient humidity
  • Poor quality food
  • Fat
  • Hyperthermia
  • Micturition problems

Integrity and Healthy Life Plan Objectives and results Education for sensitive skin:

The following objectives and results contribute to reducing the risk of damage to skin integrity.

  • Intact skin
  • Removal of redness from the skin
  • Increased skin healing
  • Good hydration
  • Preservation of physical activity
  • Better nutrition plan
  • Avoid under constant pressure
  • Suppression of swelling
  • Stability workstations

Nursing Diagnosis of Impaired Skin Integrity

Diagnosis of breastfeeding with skin integrity disorders:

Diagnosis and assessment by the nursing staff will help you prevent skin damage and can lead to care plans that compromise the integrity of the skin.

  • Examine the patient’s skin condition. Make sure that the client has healthy skin, i.e. free of injuries, lightning strikes, cuts, rashes or damage. Aging skin is less elastic and less moist, which increases the risk of skin damage.
  • Check every fracture, stretched muscle, sacrum, etc., as stretched areas cause serious problems with skin integrity. People with light skin may have a red stain on the affected area, and people with dark skin may have a blue, red or purple stain on the affected areas.
  • Learn to feel the patient under pressure. Most people change position when working or sleeping; this automatically improves their pressure and reduces the risk of integrity problems.  However, if a person does not change position for an extended period of time, this can lead to skin ischemia.
  • The risk of pressure sores also increases when the integrity of the skin is compromised. Therefore, the nursing staff should keep the patient under observation for a minimum of 24-48 hours and a maximum of four weeks in order to thoroughly examine the patient and the changes.
  • Evaluate the patient’s mobility, moisture content of the skin, sensory pressure, movement and perception on a daily basis. Sometimes it is also known as the Braden Ladder.
  • Monitor your physical condition, mental health, activity plan and physical mobility on the Norton scale to quickly and easily understand the whole picture.
  • View the patient’s diet, weight gain and loss and albumin content. Make sure that the albumin content is greater than 2.5 g/dL, otherwise there is a high risk of protein breakdown or skin problems.
  • Watch out for inconsistencies in urination. Feces can lead to the formation of enzymes and cracks in the skin. The use of pads can reduce skin damage compared to normal skin changes.
  • Consider the health of the patient when performing swelling tests or diagnosing other immunological conditions. Also check the patient’s medical history of radiation, as radiation makes the skin thin and brittle.
  • Follow the patient’s routine and assess the area where the patient is being treated most of the time. This allows you to monitor the shear and friction as well as the pressure drop.
  • Maceration of the skin can be caused by moisture, so environmental conditions regarding humidity must be respected.
  • Avoid the use of steroids. Prolonged use of steroids may cause injury or staining of the paper skin.
  • The application of chemical stimuli can also lead to inflammation, itching or blistering. Therefore, avoid its use.
  • If the risk of skin integrity increases, consult your doctor daily and reassess your skin.

Integrity measures for skin care:

The following interventions can help the patient to recover as quickly as possible. These points are also useful for diagnosing skin integrity problems and developing a care plan for patients with skin integrity problems.

  • Ask the victim not to raise his or her head when lying on the bed. Instead, tell them to use a trapeze or sheets to get into bed. Rubbing heels or elbows with bedding and transferring patients without lifting them can lead to skin integrity problems.
  • Install a good quality mattress, because a 4 to 5 inch thick mattress can help reduce pressure. Moisture can also be a trap because of the moss. This intervention is offered in particular to low-risk patients.
  • Waterbeds, static or dynamic, are available for people at moderate risk, as all these mattresses contribute to deflation or inflation.
  • For high-risk patients and stage IV ulcers, a water mattress or a fluidized bed is available. It helps the patient get out of bed easily.
  • Change the patient’s position at different times. It will prevent pressure fractures. The headboard must be raised at an angle of 30 degrees to prevent it from slipping.
  • Pay attention to good nutrition and mobility. They will be useful to give you strength while you’re on the road and DLA.
  • Clean your skin twice a day with normal water. Moisten and dry the skin, especially the bones, earlier. These operations are resistant to skin damage.
  • To increase the blood circulation of the skin, massage the affected areas daily.
  • Teach the patient the basics of skin care in critical situations.
  • If the patient has terrible diet plans, refer them to a dietician.
  • WOCN helps patients, nurses and their families in emergency situations. They help someone learn about prevention plans. For example, contact with WOCN means wound, stoma, continent and nurse.



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