Maintaining the integrity of the skin is crucial for the overall health and well-being of a patient. Factors such as poor hygiene, limited mobility, and certain medical conditions can increase the risk for deterioration of cutaneous integrity, leading to complications such as infection and difficulty healing. The nursing diagnosis of “Risk of Deterioration of Cutaneous Integrity” is used to identify and address these potential issues before they become a problem.
NANDA Nursing Diagnosis Definition
According to NANDA International, the official definition of this diagnosis is: “A potential disruption in the normal structure and function of the skin, characterized by an increased likelihood of breakdown, ulceration, and possible infection due to identified factors.”
Defining Characteristics
Subjective:
- Patient reports factors that increase the likelihood of skin breakdown (e.g. limited mobility, poor nutrition)
Objective:
- Observation of factors that increase the likelihood of skin breakdown (e.g. limited mobility, poor nutrition)
Related Factors
- Inadequate hygiene
- Poor nutrition
- Certain medical conditions (e.g. diabetes, venous insufficiency)
- Certain medications (e.g. corticosteroids, chemotherapy)
- Pressure ulcers
- Limited mobility
- Age
- Environmental factors (e.g. temperature, humidity)
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
- Impaired physical mobility
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
- Provide appropriate positioning and mobility assistance to prevent pressure ulcers
Suggested Alternative NANDA Diagnoses
- Risk for impaired skin integrity
- Risk for impaired wound healing
- Risk for infection related to impaired skin integrity
- Risk for 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 factors that increase the likelihood of skin breakdown
- Consider using additional diagnoses to address associated problems (e.g. risk for infection, impaired physical mobility)
NOC Results
- 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
- 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
- Risk Assessment: Regularly assess the patient for potential risk factors for deterioration of cutaneous integrity
- Education: Provide education to the patient and their family on how to maintain skin integrity and prevent deterioration
Conclusion
The nursing diagnosis of “Risk of Deterioration of Cutaneous Integrity” is an important tool for identifying and addressing potential issues that can lead to complications with the skin. By assessing for risk factors, providing appropriate interventions, and educating the patient, nurses can help to prevent deterioration of cutaneous integrity and promote overall health and well-being.