As a healthcare professional, it is important to be aware of the different nursing diagnoses and their implications in order to provide the best care for our patients. One of the diagnoses included in the NANDA list is “Deterioration of Tissue Integrity.” This diagnosis addresses the patient’s condition in which the skin, mucous membrane or subcutaneous tissue of the body are damaged. It is important for nurses to be able to recognize and address this diagnosis in order to provide appropriate care for their patients.
NANDA Nursing Diagnosis Definition
According to NANDA, the definition of “Deterioration of Tissue Integrity” is “Impaired integrity of the skin, mucous membrane, or subcutaneous tissue, that is at risk for injury.”
- Pain or discomfort in the affected area
- Verbalization of concern about the appearance of the affected area
- Redness, warmth or swelling in the affected area
- Open wounds or ulcers
- Discoloration of the affected area
- Cracking or fissures in the skin
- Chronic illness
- Friction or pressure on the affected area
- Inadequate nutrition
- Impaired circulation
Patients who are at risk for “Deterioration of Tissue Integrity” include those who are elderly, have chronic illnesses, are immobile, have pressure ulcers, have poor nutrition, or have impaired circulation.
- Decreased mobility
- Decreased quality of life
- Increased healthcare costs
Suggestions for Use
- Assess the patient’s skin, mucous membrane, or subcutaneous tissue for signs of deterioration
- Implement strategies to prevent further deterioration, such as repositioning, nutrition, and skin care
- Regularly re-evaluate the patient’s condition and make necessary adjustments to their care plan
Suggested Alternative NANDA Diagnoses
- Impaired physical mobility
- Impaired skin integrity
- Ineffective tissue perfusion
- Consider the patient’s individual needs and abilities when implementing interventions
- Evaluate the effectiveness of the interventions
- Involve the patient and their family in the care plan to ensure their understanding and cooperation in implementing interventions.
- Consult with other healthcare professionals, such as wound care specialists, to ensure the best possible outcomes.
- Tissue Integrity: The patient’s skin, mucous membrane, or subcutaneous tissue is maintained in a healthy state, with minimal deterioration.
- Pain management: The patient’s pain is effectively managed and minimized as a result of interventions.
- Infection control: The patient’s risk for infection is reduced as a result of interventions and appropriate wound care.
- Skin and wound care: This intervention involves assessment, cleaning, and dressing of the affected area to promote healing and prevent further deterioration.
- Repositioning: This intervention involves regularly turning and positioning the patient to reduce pressure and friction on the affected area.
- Nutrition management: This intervention involves ensuring the patient receives adequate nutrition to support the healing process and maintain tissue integrity.
NANDA’s “Deterioration of Tissue Integrity” nursing diagnosis addresses the patient’s condition in which the skin, mucous membrane or subcutaneous tissue of the body are damaged. It is important for nurses to be able to recognize and address this diagnosis in order to provide appropriate care for their patients. By assessing the patient’s condition, implementing preventative measures and involving the patient and their family in the care plan, nurses can help to maintain tissue integrity, reduce the patient’s risk for infection, and minimize pain.