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).