Due to decreased sensation to the lower legs and feet, the patient must keep feet protected to prevent skin injury. There are a lot of people suffering from malnutrition. Stumped on Nursing Diagnosis for Episiotomy - allnurses She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process and help nursing students pass the NCLEX exams. Ferreira KCB, Valle ABCDS, Paes CQ, Tavares GD, Pittella F. Pharmaceutics. Regularly assess condition for bedsores. Healthy skin varies from individual to individual, but should have good turgor (an indication of moisture), feel warm and dry to the touch, be free of impairment, and have quick capillary refill (less than 6 seconds). Care Plan Impaired Skin Integrity Related Immobility below. Diabetic Foot Ulcer Nursing Diagnosis & Care Plan Assess the patients fluid balance and determine the steps necessary to restore or maintain it. One of the primary reasons for this is that a persons body is unable to absorb nutrients because food cannot be digested properly. St. Louis, MO: Elsevier. The following sections will discuss malnutrition in detail. St. Louis, MO: Elsevier. Adhesive removers make taking the pouch off easier without damaging the skin. Ensure socks or non-slip footwear is worn at all times. Potential for impaired gas exchanges in pulmonary system Other diagnosis as identfied Risk for: peripheral neurovascular dysfunction; ineffective coping: impaired skin integrity; for infection. Nursing Diagnosis: Imbalanced Nutrition: Less than the body requirements related to reluctance to consume meals, secondary to malnutrition as evidenced by an imbalance in electrolytes, ineffective healing of wounds, reductions in the level of protein, transferrin, and serum albumin concentration, loss of muscle tone and a weight decrease of less than 20%. The skin is the bodys outermost defense system that keeps pathogens from entering and causing illness. (2020). Elderly, especially those who live alone or are disabled. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Perform skin assessments. Evidence-based nursing intervention to reduce skin integrity impairment in children with diaper dermatitis: A systematic review . Once the subcutaneous tissue is involved, impaired tissue integrity is the diagnosis that needs to be used. Despite the lack of evidence that spot reduction or mechanical gears can assist people in losing weight, certain activities or equipment may be able to tone certain body areas. Pressure ulcer education 3: skin assessment and care Nursing Diagnosis: Impaired Physical Mobility. Dehydration can cause further skin injury due to skin dryness. Nursing Diagnosis: Impaired Skin Integrity related to infective process of necrotizing fasciitis as evidenced by positive tissue biopsy result, gangrenous skin tissue, erythema, and pain on the affected site. eCollection 2022 Sep. Almeida C, Filipe P, Rosado C, Pereira-Leite C. Nanomaterials (Basel). Intake of high protein foods and supplements is essential for repairing body tissues. The patient presents to the hospital and is diagnosed with type 2 diabetes. Nursing Care Plan for: Impaired Skin Integrity, Risk for Skin Breakdown, Altered Skin Integrity, and Risk for Pressure Ulcers. Numbness to affected and surrounding skin, Changes to skin color (erythema, bruising, blanching), Observed open areas or breakdown, excoriation, Patient will maintain intact skin integrity, Patient will experience timely healing of wounds without complications, Patient will verbalize proper prevention of pressure injuries.
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