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NURSING DIAGNOSIS: Skin/Tissue Integrity, impaired May be related to Invasion of body structure (e.g., perineal resection) Stasis of secretions/drainage Altered circulation, edema; malnutrition Possibly evidenced by Disruption of skin/tissue: presence of incision and sutures, drains Desired Outcomes Wound Healing: Primary Intention (NOC) Achieve timely wound healing free of signs of infection. 10 Ileostomy & Colostomy Nursing Care Plan (NCP) Risk for ...

NURSING DIAGNOSIS: Skin Integrity, risk for impaired Risk factors may include Absence of sphincter at stoma Character/flow of effluent and flatus from stoma Reaction to product/chemicals; improper fitting/care of appliance/skin Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] Desired Outcomes Bowel Elimination (NOC) Maintain skin integrity around stoma. Identify individual risk factors. Demonstrate behaviors/techniques to promote ...

NURSING DIAGNOSIS: Skin Integrity, risk for impaired Risk factors may include Prolonged bedrest Edema, decreased tissue perfusion Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] Desired Outcomes Tissue Perfusion: Peripheral (NOC) Maintain skin integrity. Demonstrate behaviors/techniques to prevent skin breakdown. 6 Heart Failure Nursing Care Plan (NCP) Decreased Cardiac Output — Heart Failure (CHF) Nursing Care Plan (NCP) ...

NURSING DIAGNOSIS: Skin/Tissue Integrity, risk for impaired Risk factors may include Chemical substance: bile salt accumulation in the tissues Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Tissue Integrity: Skin and Mucous Membranes (NOC) Display intact skin/tissues, free of excoriation. Report absence/decrease of pruritus/scratching. 7 Hepatitis Nursing Care Plan (NCP) Imbalanced Nutrition — ...

NURSING DIAGNOSIS: Skin Integrity, risk for impaired Risk factors may include Altered nutritional/metabolic state; edema Dehydration/cachectic changes (skeletal prominence) Possibly evidenced by [Not applicable; presence of signs and symptoms establishes and actual diagnosis.] Desired Outcomes Verbalize understanding of causative factors and absence of itching. Identify and demonstrate behaviors to maintain soft, supple, intact skin. 7 Eating Disorders (Anorexia & Bulimia Nervosa) Nursing ...

NURSING DIAGNOSIS: Skin Integrity, risk for impaired Risk factors may include Altered circulation/metabolic state Accumulation of bile salts in skin Poor skin turgor, skeletal prominence, presence of edema, ascites Desired Outcomes Maintain skin integrity. Identify individual risk factors and demonstrate behaviors/techniques to prevent skin breakdown. 8 Liver Cirrhosis Nursing Care Plan (NCP) Imbalanced Nutrition — Liver Cirrhosis Nursing Care Plan (NCP) Excess ...

NURSING DIAGNOSIS: Impaired Skin Integrity May be related to Chemical substance (bile), stasis of secretions Altered nutritional state (obesity)/metabolic state Invasion of body structure (T-tube) Possibly evidenced by Disruption of skin/subcutaneous tissues Desired Outcomes Achieve timely wound healing without complications. Demonstrate behaviors to promote healing/prevent skin breakdown. 4 Cholecystectomy Nursing Care Plan (NCP) Ineffective Breathing Pattern — Cholecystectomy Nursing Care Plan ...

Nursing Diagnosis: Skin/Tissue Integrity, impaired: actual/risk for May be related to Puncture injury; compound fracture; surgical repair; insertion of traction pins, wires, screws Altered sensation, circulation; accumulation of excretions/secretions Physical immobilization Possibly evidenced by (actual) Reports of itching, pain, numbness, pressure in affected/surrounding area Disruption of skin surface; invasion of body structures; destruction of skin layers/tissues Desired Outcomes Verbalize relief ...