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Impaired Skin integrity

Defining Characteristics

Destruction of skin layers; disruption of skin surface; invasion of body structures

Related Factors (r/t)

External

Chemical substance; extremes in age; humidity; hyperthermia; hypothermia; mechanical


factors (e.g., friction, shearing forces, pressure, restraint); medications; moisture; physical
immobilization; radiation

Internal

Changes in fluid status; changes in pigmentation; changes in turgor; developmental


factors; imbalanced nutritional state (e.g., obesity, emaciation); immunological deficit;
impaired circulation; impaired metabolic state; impaired sensation; skeletal prominence

NOC
Outcomes (Nursing Outcomes Classification)
Suggested NOC Outcomes

• Wound Healing: Primary Intention


• Secondary Intention

Client Outcomes

Client Will (Specify Time Frame)

• Regain integrity of skin surface


• Demonstrate understanding of plan to heal skin and prevent reinjury
• Describe measures to protect and heal the skin and to care for any skin lesion

NIC
Interventions (Nursing Interventions Classification)
Suggested NIC Interventions
• Incision Site Care
• Skin Surveillance

Nursing Interventions and Rationales

• Assess site of skin impairment and determine cause (e.g., acute or chronic wound,
burn, dermatological lesion, pressure ulcer, skin tear). EB: The cause of the
wound must be determined before appropriate interventions can be implemented.
This will provide the basis for additional testing and evaluation to start the
assessment process (Baranoski & Ayello, 2003).
• Monitor site of skin impairment at least once a day for color changes, redness,
swelling, warmth, pain, or other signs of infection. Determine whether the client
is experiencing changes in sensation or pain. Pay special attention to high-risk
areas such as bony prominences, skinfolds, the sacrum, and heels. Systematic
inspection can identify impending problems early (Ayello & Braden, 2002).
• Monitor the client's skin care practices, noting type of soap or other cleansing
agents used, temperature of water, and frequency of skin cleansing.
• Individualize plan according to the client's skin condition, needs, and preferences.
EBN: Avoid harsh cleansing agents, hot water, extreme friction or force, or
cleansing too frequently (Panel for the Prediction and Prevention of Pressure
Ulcers in Adults, 1992; Wound, Ostomy, and Continence Nurses Society WOCN
2003).
• Monitor the client's continence status, and minimize exposure of skin impairment
and other areas of moisture from incontinence, perspiration, or wound drainage.
EBN: Moisture from incontinence contributes to pressure ulcer development by
macerating the skin (WOCN, 2003).
• Do not position the client on site of skin impairment. If consistent with overall
client management goals, turn and position the client at least every 2 hours.
Transfer the client with care to protect against the adverse effects of external
mechanical forces such as pressure, friction, and shear.
• Implement a written treatment plan for topical treatment of the site of skin
impairment. A written plan ensures consistency in care and documentation
(Baranoski & Ayello, 2003; Maklebust & Sieggreen, 2001).
• Select a topical treatment that will maintain a moist wound-healing environment
and that is balanced with the need to absorb exudate. EBN: Choose dressings that
provide a moist environment, keep periwound skin dry, and control exudate and
eliminate dead space (WOCN, 2003).
• Assess the client's nutritional status. Refer for a nutritional consult and/or institute
dietary supplements as necessary. Optimizing nutritional intake, including
calories, fatty acids, protein, and vitamins, is needed to promote wound healing
(Russell, 2001). EB: The benefit of nutritional evaluation and intensive
nutritional support in clients at risk for and with pressure ulcers is not supported
by rigorous clinical trials. Despite this lack of evidence, NPUAP (2006) endorses
the application of reasonable nutritional assessment and treatment for clients at
risk for and with pressure ulcers.
• Identify the client's phase of wound healing (inflammation, proliferation,
maturation) and stage of injury. Accurate understanding of tissue status combined
with knowledge of underlying diagnoses and product validity provide a basis for
determining appropriate treatment objectives. No single wound dressing is
appropriate for all phases of wound healing (Ovington, 1999).

Home Care

• Instruct and assist the client and caregivers in how to change dressings and
maintain a clean environment. Provide written instructions and observe them
completing the dressing change.
• Educate client and caregivers on proper nutrition, signs and symptoms of
infection, and when to call the agency and/or physician with concerns.

Client/Family Teaching

• Teach skin and wound assessment and ways to monitor for signs and symptoms of
infection, complications, and healing. Early assessment and intervention help
prevent serious problems from developing.

REFERENCES

Constipation
Defining Characteristics

Abdominal pain; abdominal tenderness with palpable muscle resistance; abdominal


tenderness without palpable muscle resistance; anorexia; atypical presentations in older
adults (e.g., change in mental status, urinary incontinence, unexplained falls, elevated
body temperature); borborygmi; bright red blood with stool; change in bowel pattern;
decreased frequency; decreased volume of stool; distended abdomen; feeling of rectal
fullness; feeling of rectal pressure; generalized fatigue; hard; formed stool; headache;
hyperactive bowel sounds; hypoactive bowel sounds; increased abdominal pressure;
indigestion; nausea; oozing liquid stool; palpable abdominal mass; palpable rectal mass;
presence of soft; paste-like stool in rectum; percussed abdominal dullness; pain with
defecation; severe flatus; straining with defecation; unable to pass stool; vomiting

Related Factors (r/t)

Functional

Abdominal muscle weakness; habitual denial; habitual ignoring of urge to defecate;


inadequate toileting (e.g., timeliness, positioning for defecation, privacy); irregular
defecation habits; insufficient physical activity; recent environmental changes
Psychological

Depression; emotional stress; mental confusion

Pharmacological

Aluminum containing antiacids; anticholinergics; anticonvulsants; antidepressants;


antilipemic agents; bismuth salts; calcium carbonate; calcium channel blockers; diuretics;
iron salts; laxative overuse use; nonsteroidal anti-inflammatory drugs; opiates;
phenothiazines; sedatives; sympathomimetics

Mechanical

Electrolyte imbalance; hemorrhoids; Hirschsprung's disease; neurological impairment;


obesity; postsurgical obstruction; pregnancy; prostate enlargement; rectal abscess; rectal
anal fissures; rectal anal stricture; rectal prolapse; rectal ulcer; rectocele; tumors

Physiological

Change in eating patterns; change in usual foods; decreased motility of gastrointestinal


tract; dehydration; inadequate dentition; inadequate oral hygiene; insufficient fiber intake;
insufficient fluid intake; poor eating habits

NOC
Outcomes (Nursing Outcomes Classification)
Suggested NOC Outcomes

• Bowel Elimination

Client Outcomes

Client Will (Specify Time Frame)

• State relief from discomfort of constipation


NIC
Interventions (Nursing Interventions Classification)
Suggested NIC Intervention

• Constipation/Impaction Management

Nursing Interventions and Rationales

• Assess usual pattern of defecation, including time of day, amount and


frequency of stool, consistency of stool; history of bowel habits or laxative
use; diet, including fiber and fluid intake; exercise patterns; personal remedies
for constipation; obstetrical/gynecological history; surgeries; diseases that
affect bowel motility; alterations in perianal sensation; present bowel regimen.
There often are multiple reasons for constipation; the first step is assessment
of the usual patterns of bowel elimination.
• Review the client's current medications. EB: Many medications are associated
with chronic constipation including opiates, antidepressants, antispasmodics,
diuretics, anticonvulsants, and antacids containing aluminum (Talley et al,
2003).
• If the client is receiving temporary opioids (e.g., for acute postoperative pain),
request an order for routine stool softeners from the primary care practitioner,
monitor bowel movements, and request a laxative if the client develops
constipation. If the client is receiving round-the-clock opiates (e.g., for
palliative care), request an order for Senokot-S and institute a bowel regimen.
Opioids lead to constipation because they decrease propulsive movement in
the colon and enhance sphincter tone, making it difficult to defecate.
Senokot-S is recommended to prevent constipation when opioids are given
round the clock (Robinson et al, 2000).
• If new onset of constipation, determine if the client has recently stopped
smoking. EB: Constipation happens in one in six people who stop smoking
and in some people can be very severe (Hajek, Gillison & McRobbie, 2003).
• Palpate for abdominal distention, percuss for dullness, and auscultate bowel
sounds. In clients with constipation the abdomen is often distended and
tender, and stool in the colon produces a dull percussion sound. Bowel sounds
will be present (Hinrichs et al, 2001).
• If the client is uncomfortable or in pain due to constipation or has acute or
chronic constipation that does not respond to increased fiber, fluid, activity,
and appropriate toileting, refer the client to the primary care practitioner for
an evaluation of bowel function and health status. There can be multiple
causes of constipation, such as hypothyroidism, depression, somatization,
bowel obstruction, and Hirschsprung's disease (Arce, Ermocilla & Costa,
2002).
• Encourage a fluid intake of 1.5 to 2 L/day (six to eight glasses of liquids per
day), unless contraindicated because of renal insufficiency. Cereal fibers such
as wheat bran add additional bulk by attracting water to the fiber, so
adequate fluid intake is essential. Increasing fluid intake to 1.5 to 2 L/day
while maintaining a fiber intake of 25 g can significantly increase the
frequency of stools in clients with constipation (Weeks, Hubbartt & Michaels,
2000; Anti, 1998). EB: Increasing fluid intake is not helpful if the person is
already well hydrated (Muller-Lissner et al, 2005).
• Encourage clients to resume walking and activities of daily living as soon as
possible if their mobility has been restricted. Encourage turning and changing
positions in bed, lifting the hips off the bed, performing range-of-motion
exercises, alternately lifting each knee to the chest, doing wheelchair lifts,
doing waist twists, stretching the arms away from the body, and pulling in the
abdomen while taking deep breaths. Bed rest and decreased mobility lead to
constipation, but additional exercise does not help the constipated person
who is already mobile. When the client has diminished mobility, even minimal
activity increases peristalsis, which is necessary to prevent constipation
(Weeks, Hubbartt & Michaels, 2000). EB: Twelve weeks of physical activity
significantly decreased symptoms of constipation and difficulty defecating in
sedentary clients with chronic constipation, but transit time decreased only in
subjects who had abnormally long transit time before starting the exercise
program (DeSchryver et al, 2005).
• Provide privacy for defecation. If not contraindicated, help the client to the
bathroom and close the door. Bowel elimination is a private act in Western
cultures, and a lack of privacy can hinder the defecation urge, thus
contributing to constipation (Weeks, Hubbartt & Michaels, 2000).
• Help clients onto a bedside commode or toilet so they can either squat or lean
forward while sitting. EB: An experimental study of 10 healthy young men
found that flexing the hip to 90 degrees or more straightens the angle
between the anus and the rectum and pulls the anal canal open, to decrease
the resistance to the movement of feces from the rectum and the amount of
pressure needed to empty the rectum. Hip flexion is greatest when squatting
or when leaning forward while sitting (Tagart, 1966). Sitting upright also
allows gravity to aid defecation (Weeks, Hubbartt & Michaels, 2000).
• Teach clients to respond promptly to the defecation urge. EB: A study of 12
healthy male volunteers determined that the defecation urge can be delayed
and that delaying defecation decreased bowel movement frequency, stool
weight, and transit time (Klauser et al, 1990).
• Provide laxatives, suppositories, and enemas only as needed if other more
natural interventions are not effective, and as ordered only; establish a client
goal of eliminating their use. Use of stimulant laxatives should be avoided
because they result in laxative dependence and loss of normal bowel function
(Merli & Graham, 2003). Laxatives and enemas also damage the surface
epithelium of the colon (Schmelzer et al, 2004).

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