Impaired skin integrity r/t traction application

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Definition

Altered epidermis and/or dermis (The integumentary system is the largest multifunctional organ of the body)

Related Factors:

External

• Hyperthermia or hypothermia
• Chemical Substance; Radiation; Medications
• Physical Immobilization
• Humidity; Moisture; (excretions/secretions)
• Altered Fluid Status
• Mechanical Factors (e.g., shearing forces, forces, pressure, restraint), [trauma:injury/surgery]
• Extremes in Age

Internal

• Altered Nutritional State ( e.g., obesity, emaciation); metabolic state; fluid status
• Skeletal Prominence; alterations in turgor ( change in elasticity); [Presence of Edema]
• Altered Circulation; sensation; pigmentation
• Developmental Factors
• Immunological Deficit
• [Psychogenic]

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• Impaired skin integrity r/t changes in the barrier function of the skin Definition Altered epidermis and/or dermis (The integumentary system is the largest multifunctional organ of the body) Related Factors: External Hyperthermia or hypothermia Chemical Substance; Radiation; Medications Physical Immobilization Humidity; Moisture; (excretions/secretions) Altered Fluid Status Mechanical Factors (e.g., shearing forces, forces, pressure, restraint), [trauma:injury/surgery] Extremes in Age Internal Altered Nutritional State ( e.g., obesity, emaciation); metabolic state; fluid status Skeletal Prominence; alterations in turgor ( change in elasticity); [Presence
• Impaired adjustment r/t health status requiring change in lifestyle Definition Inability to modify lifestyle/behavior in a manner consistent with a change in health status Related Factors Disability or health status requiring change in lifestyle Mulitple stressors; intense emotional state Low state of optimism; negative attitude towards health behavior; lack of motivation to change behavior Failure to intend to change behavior Absence of social support for changed beliefs and practices (Physical and/or learning
• Impaired Urinary Elimination r/t oral fluid/solid restriction & sensory motor impairment Definition Disturbance in urine elimination Related Factors Multiple Causality sensory motor impairment anatomical obstruction Urinary Tract Infection (UTI) Mechanical trauma Fluid/volume states Sychogenic factors Surgical diversion *You need an acrobat reader to view this file Click on the icon to download acrobat reader VIEW NCP
• Risk for uterine infection r/t lochia and episiotomy  Definition At increased risk for being invaded by pathogenic organisms Related Factors Inadequate primary defense (broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids, change in pH secretions, altered peristalsis) Inadequate secondary defenses (e.g. decreased hemoglobin, leukopenia, suppressed inflammatory response) and immunosuppression Inadequate acquired immunity; tissue destruction and increased environmental exposure; invasive procedures Pharmaceutical agents (including antibiotic therapy) Rupture
• Impaired verbal communication r/t loss of facial or oral muscle tone control Definition Decreased, delayed, or absentability to receive, process, transmit, and use a system of symbols Related Factors Decrease in circulation to brain, brain tumor Anatomic deficit ( e.g. cleft palate, alteration of the neurovascular visual system, auditory system, or phonatory apparatus) Difference related to developmental age Physical barrier ( tracheostomy, intubation) Physiological conditions (e.g. dyspnea ); alteration of central nervous system (CNS);