Introduction to NANDA Nursing Diagnosis: Risk of Tissue Integrity Deterioration
At the forefront of health care is the concept of risk management. When assessing patients, nurses must be aware of any risks that may be present and how to intervene. One such risk is tissue integrity deterioration, which is determined by a set of criteria set forth by NANDA International (NANDA-I).
NANDA Nursing Diagnosis Definition
NANDA’s definition of “Risk for Tissue Integrity Deterioration” is: The state in which an individual has limited ability to maintain protective or functional integrity of skin, mucous membranes, and other tissue systems that may be vulnerable to insults or injuries.
Defining Characteristics
Subjectives
- Reports sensation of numbness or tingling
- Reports feeling of coolness at the site of tissue
- Reports presence of pain at the site of tissue
Objectives
- Change in temperature of tissue
- Edges of wound base that are not joined together
- Appearance of powdery substances on skin of affected area
- Presence of debris, pus, or necrotic tissue
Related Factors
- Insufficient knowledge about prevention of tissue trauma
- Friction from inadequate skin preparation prior to invasive procedures
- Pressure from inadequate padding during invasive procedures
- Shearing forces from wrong body positioning during transfers
- Nutritional deficits
- Fluid and electrolyte deficits
Risk Population
- Elderly
- Immunocompromised
- Bedrest Or Immobility
- Multiple Acute Health Conditions
- Exposed To Extremes Of Temperature
- Use Of Prolonged Treatment Methods
Associated Problems
- Skin Infection
- Susceptibility to Pressure Ulcers
- Tissue Trauma
- Tissue Hypoxia/Ischemia
Suggestions for Use
- Evaluate tissue integrity frequently
- Assess the patient’s risk factors
- Implement preventive interventions
- Inform the patient and family
Suggested Alternative NANDA Diagnoses
- At Risk for Ineffective Tissue Perfusion
- Impaired Skin Integrity
- Risk for Infection
- Impaired Physical Mobility
- Risk for Falls
Usage Tips
- It is important to differentiate between acute causes of tissue integrity deficit such as friction and shear, versus chronic causes such as nutritional deficiencies or compromised immune system.
- It is also important to assess the patient’s environment, including temperature, humidity, positioning, and any medical or surgical devices used.
- It should be noted that this diagnosis applies to all tissue types, not just skin.
NOC Results
- Tissue Integrity: Elevated potential for physical injury from environmental factors and health disturbances.
- Pressure Ulcer Status: Degree of tissue destruction and healing in response to pressure.
- Tissue Healing: Repair of compromised tissue.
- Risk Control: Ability to identify, manage and reduce environmental risk.
- Self-care Ability: Ability to perform independent self-care needs.
NIC Interventions
- Preventative Skin Care: Utilizing practices and interventions to prevent skin breakdown.
- Skin Surveillance: Ongoing monitoring of the skin condition.
- Protective Measures: Providing supportive devices, support surfaces, and skin protectants as appropriate.
- Wound Care: Applying wound cleaning and dressing protocols.
- Transitional Care Planning: Developing strategies for continuity of care.
- Educating About Skin Care: Teaching self-care measures, including proper positioning and nutrition.
Conclusion
NANDA’s Risk of Tissue Integrity Deterioration diagnosis helps nurses understand the risk factors associated with tissue integrity loss, and provides interventions to ensure the best possible outcomes. By utilizing risk assessments, preventive measures, and educational interventions, nurses can reduce the incidence and magnitude of tissue integrity deterioration.
FAQs
- What is NANDA’s definition of Risk for Tissue Integrity Deterioration?
NANDA’s definition of “Risk for Tissue Integrity Deterioration” is: The state in which an individual has limited ability to maintain protective or functional integrity of skin, mucous membranes, and other tissue systems that may be vulnerable to insults or injuries. - What are some Suggested Alternative NANDA Diagnoses for Risk for Tissue Integrity Deterioration?
Some Suggested Alternative NANDA Diagnoses for Risk for Tissue Integrity Deterioration are: At Risk for Ineffective Tissue Perfusion, Impaired Skin Integrity, Risk for Infection, Impaired Physical Mobility, and Risk for Falls. - What are some usage tips for Risk for Tissue Integrity Deterioration?
Some usage tips for Risk for Tissue Integrity Deterioration include: differentiating between acute and chronic tissue integrity deficits, assessing the patient’s environment (temperature, humidity, positioning, etc.), and noting that this diagnosis applies to all tissue types (not just skin).