The skin is the body’s largest organ and plays a vital role in protecting the body from infection, injury, and dehydration. When the integrity of the skin is compromised, it can lead to a variety of problems, including infection, pain, and difficulty healing. One common nursing diagnosis for this type of problem is “Deterioration of Cutaneous Integrity.”
NANDA Nursing Diagnosis Definition
According to NANDA International, the official definition of this diagnosis is: “A disruption in the normal structure and function of the skin, characterized by breakdown, ulceration, and possible infection.”
Defining Characteristics
Subjective:
- Patient reports pain or discomfort in the affected area
- Patient reports difficulty healing
- Patient reports a change in the appearance of the affected area (e.g. redness, swelling, ulceration)
Objective:
- Breakdown or ulceration of the skin is observed
- Patient has difficulty healing
- Patient has a change in the appearance of the affected area (e.g. redness, swelling, ulceration)
Related Factors
- Inadequate hygiene
- Poor nutrition
- Certain medical conditions (e.g. diabetes, venous insufficiency)
- Certain medications (e.g. corticosteroids, chemotherapy)
- Pressure ulcers
Risk Population
- Older adults
- Individuals with chronic medical conditions
- Individuals who are bedridden or have limited mobility
- Individuals who are receiving certain types of medical treatment (e.g. corticosteroids, chemotherapy)
Associated Problems
- Infection
- Pain
- Difficulty healing
- Malnutrition
- Dehydration
Suggestions for Use
- Assess the patient’s hygiene and provide instruction as needed
- Assess the patient’s nutrition and provide nutrition education as needed
- Assist the patient in managing any underlying medical conditions (e.g. diabetes, venous insufficiency)
- Monitor the patient for signs of infection and implement appropriate interventions
- Provide wound care as needed
Suggested Alternative NANDA Diagnoses
- Impaired Skin Integrity
- Impaired Wound Healing
- Risk for Infection related to impaired skin integrity
- Impaired Physical Mobility related to impaired skin integrity
Usage Tips
- Consider the patient’s overall health status and any underlying medical conditions when making a diagnosis
- Be specific when documenting the appearance of the affected area (e.g. redness, swelling, ulceration)
- Consider using additional diagnoses to address associated problems (e.g. risk for infection, impaired physical mobility)
NOC Results and Explanation
- Skin Integrity: The patient’s skin is intact and functioning properly
- Wound Healing: The patient’s wound is healing properly
- Infection Control: The patient is free from infection and appropriate interventions are in place to prevent infection
NIC Interventions and Explanation
- Skin Care: Provide appropriate skin care to maintain integrity of skin
- Wound Care: Administer wound care as needed to promote healing
- Infection Control: Implement appropriate infection control measures to prevent and manage infection
- Nutrition Support: Provide appropriate nutrition support to maintain skin integrity and prevent malnutrition
- Mobility Assistance: Provide assistance with mobility to prevent pressure ulcers and promote healing
Conclusion
Deterioration of cutaneous integrity is a serious condition that can lead to a variety of problems, including infection, pain, and difficulty healing. It is important for nurses to be aware of the risk factors, associated problems, and interventions for this diagnosis in order to provide effective care for patients.