Impaired Skin integrity


Altered epidermis and/or dermis

Defining Characteristics:
  • Invasion of body structures; 
  • destruction of skin layers (dermis); 
  • disruption of skin surface (epidermis)

Related Factors:

External
  • Hyperthermia; 
  • hypothermia; 
  • chemical substance (e.g., incontinence); 
  • mechanical factors (e.g., friction, shearing forces, pressure, restraint); 
  • physical immobilization; 
  • humidity; 
  • extremes in age; 
  • moisture; 
  • radiation; 
  • medications
Internal
  • Altered metabolic state; 
  • altered nutritional state (e.g., obesity, emaciation); 
  • altered circulation; 
  • altered sensation; 
  • altered pigmentation; 
  • skeletal prominence; 
  • developmental factors; 
  • immunological deficit; 
  • alterations in skin turgor (change in elasticity); 
  • altered fluid status

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Tissue Integrity: Skin and Mucous Membranes
  • Wound Healing: Primary Intention
  • Wound Healing: Secondary Intention

Client Outcomes
  • Regains integrity of skin surface
  • Reports any altered sensation or pain at site of skin impairment
  • Demonstrates understanding of plan to heal skin and prevent reinjury
  • Describes measures to protect and heal the skin and to care for any skin lesion

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Incision Site Care
  • Pressure Ulcer Care
  • Skin Care: Topical Treatments
  • Skin Surveillance Wound Care

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