Risk For Impaired Skin Integrity Research Articles

RISK MANAGEMENT IN SURGICAL CLINICAL UNIT

Objective: Identify the health risks patients/workers are exposed to in the surgical clinic of a hospital in the north of Minas Gerais. Method: This is an experience report, the instruments used were: Risk Map – Sector Diagnosis, ANVISA General Standards and Structure Assessment, Risk Mapping Objective: Identify which health risks patients/workers are exposed to from nursing service and Strategic Planning. Results: The risk factors found and highlighted as priorities in the clinical diagnosis of this study were: risk of bleeding, risk of infection, risk of impaired skin integrity, risk of injury, risk of falls, risk of shock and risk of unstable blood glucose. Nurse intervention is of great importance in reducing or even eliminating damage resulting from illness and hospitalization. Conclusion: The study in question provided knowledge to the manager and clinical nurse about the risks that the sector had.

The role of nursing care in the management of post-burn epidermal cancer: A narrative review

Severe burns, affecting over 20% of the body, induce systemic dysfunction and immune suppression, correlating with increased cancer risk, especially skin cancer. Nurses play a crucial role in averting complications, which is explored in this study through a comprehensive literature review. The literature review focused on nursing care for post-burn skin cancer; a systematic search covered databases including Magiran, Scientific Information Database, and PubMed and Google Scholar search engine. Keywords "nursing", "skin cancer", and "burn" were strategically combined with Boolean operators. From an initial 580 articles, 10 met eligibility post-screening. The results have shown that optimal care for burn patients necessitates an interdisciplinary approach with the burn nurse at its core, coordinating patient care across multiple disciplines. The nurse's responsibilities encompass a comprehensive understanding of multisystem organ failure, critical care methodologies, diagnostic procedures, and psychosocial skills. Meticulous wound care, infection prevention, and pain management are pivotal, with the nurse actively engaging in nursing research. The origin of cancers within burns involves hypotheses of persistent cell proliferation, chronic inflammation, toxin exposure, and compromised immunological defense. Nursing care, particularly in detecting and treating wound inflammation, is pivotal in preventing cancer. Nurses contribute to patient education on skin cancer prevention, emphasizing lifestyle choices and providing crucial psychological support. Nursing diagnoses, based on symptomatology studies, include "risk for impaired skin integrity", "impaired skin integrity", "acute pain", "chronic pain", and "impaired comfort". These diagnoses guide tailored interventions to prevent skin cancer incidence.In sum, nurses are pivotal in comprehensive burn care, overseeing wound care, infection prevention, and patient education on UV radiation dangers. They advocate healthy lifestyles to reduce skin cancer risk, provide psychological support, and encourage commitment to prevention practices. Nursing diagnoses guide tailored interventions, contributing to ongoing improvements in burn care and enhancing the quality of life for survivors.

Nursing care for symptoms seen in patients undergoing palliative surgery – a retrospective study

Introduction and aim. Palliative care is an approach to improve the quality of life of patients and their families facing problems associated with life-threatening illnesses or old age, to manage their pain, distress, and other symptoms, improving their quality of life, and providing psychological support. This study was designed to identify the care practices planned by nurses for the health issues of palliative surgical patients. Material and methods. This is a retrospective, cross-sectional, descriptive study. The data was collected from digital records of the two state hospitals in the Western Black Sea Region of Turkey between January 2019 and January 2020. The research was completed with a total of 391 data of patients undergoing palliative surgery. Frequency and percentage distributions were used in descriptive statistics. Results. The frequency of symptoms observed in patients were determined as cough and sputum (81.8%), dehydration (73.9%), dyspnea (71.9%), fatigue (49.9%), loss of appetite-weight (49.9%), insomnia (44%), pain (37.6%), nausea (29.2%), and constipation (23.8%). The planned nursing diagnoses for these symptoms were identified as risk for falls, imbalanced nutrition, risk for impaired skin integrity, risk for infection, risk for aspiration, deficient knowledge, risk for impaired respiratory function, constipation, ineffective airway clearance, pain, risk for deficient fluid volume, sleep deprivation, impaired gas exchange respectively. Conclusion. This study highlights the insufficient planning of nursing care for the symptoms of palliative surgical patients receiving palliative care in our country. Therefore, it is recommended that palliative care nurses be supported with in-service training on appropriate care planning topics.

Assessment of A Patient with Liver Failure According to Marjory Gordon's Functional Health Pattern Model After Liver Transplantation from A Cadaver: Case Report

Liver failure, which is common worldwide, occurs as a result of a variety of causes, including obesity, liver disease, high alcohol consumption, hepatitis B or C infection, autoimmune disease, and iron or copper overload. With advanced liver failure, the most common cause of which is chronic viral hepatitis, liver transplantation is the only treatment of choice. Recurrent hepatitis C or B infections occur as a late complication after transplantation. Both can be treated well after a liver transplant. Other chronic liver diseases may also recur. The aim of this case report is to share our knowledge and experience about the disease and the case with our colleagues. The patient's data were collected according to M. Gordon's functional health patterns. Nursing diagnoses were determined according to the North American Nurses Association (NANDA) classification. The patient was 27 years old, male, single, had a university degree, and lived with his family in a large city. The patient, whose mother also had hepatitis B, had undergone liver transplantation in 2008. In December 2021, the patient was admitted to the gastroenterology department because of increased pruritus and icteric manifestations on the sclera. Nursing diagnoses: Risk of infection due to the inability of hepatic Kupfer cells to perform phagocytosis function, fatigue, ineffective individual coping, disturbed body image due to diffuse icteric appearance, impaired liver function, risk of impaired skin integrity, and lack of knowledge. The nursing process was applied according to the identified nursing diagnoses. The patient was discharged 7 days after hospitalization following the determination of drug levels. Patient care is extremely important in the nursing profession. Planning the patient's care according to M. Gordon's Functional Health Patterns Model and conducting data analysis in line with the model's sub-dimensions were observed to solve the patient's problems in a short time, and nursing care was provided to the patient in a systematic manner.

Aspek Caring Perawat dalam Perawatan Pasien ARDS COVID-19 Terpasang Extracorporeal Membrane Oxigenation (Ecmo): Studi Kasus dengan Pendekatan Teori Keperawatan Care, Core and Cure Lydia Hall

This study aims to provide an overview of nurses' caring in carrying out critical nursing care for Covid-19 patients installed with Extracorporeal Membrane Oxygenation (ECMO) in the ICU using the Care, Core, Cure Lydia Hall nursing theory. This type of research is qualitative research with a case study approach. The results showed that nursing problems that occurred in patients after ECMO installation included airway disorders, gas exchange disorders, bleeding risks, and the risk of impaired skin integrity due to decreased tissue perfusion. In conclusion, Lydia Hall's nursing theory is dominated by the Cure aspect because the installation of ECMO is a very complex medical procedure and involves teams from various disciplines. Hence, the implementation of the Cure aspect is a collaborative act of nurses. Care and Core aspects also have an essential role in caring for nurses, namely by conducting therapeutic interactions and facilitating patients to get family support so that patients have the spirit to recover and do not experience stress that can affect hemodynamic conditions.
 
 Keywords: COVID-19, ECMO, ICU, Lydia Hall, Case Study

Nursing diagnoses of hospitalized infants with physiologic hyperbilirubinemia: A cross sectional study

Background and aimNursing diagnoses are the common language of nurses which indicate the labels given to human responses to health problems/developmental processes. Neonatal physiologic hyperbilirubinemia is a developmental disorder common in neonates. The responses to this health problem need to be identified.This study aimed to find physiologic hyperbilirubinemia related nursing diagnoses in some domains of the NANDA-I classification in hospitalized newborns in a maternal-neonatal educational hospital in Tehran, Iran. MethodsIn this cross-sectional study, a checklist contains labels, defining characteristics and related factors of selected nursing diagnosis of six domains of the NANDA-I classification and a maternal-neonatal information questionnaire were used for conveniently selected 140 hospitalized newborns with physiologic hyperbilirubinemia. The data was analyzed using SPSS software 23 (IBM Corp, Armonk, NY). FindingsRisk for deficient fluid volume, Risk for electrolyte imbalance (hyponatremia/hypocalcemia/hypernatremia), risk for vascular trauma, risk for impaired skin integrity, risk for infection, risk for injury (retinal damage/bilirubin hyperbilirubinemia) and risk for thermal injury were the nursing diagnoses identified for more than 90% of the neonates. ConclusionThe nursing diagnoses identified in this study for physiologic neonatal hyperbilirubinemia can guide clinical neonatal nurses in providing high-quality care in neonatal settings.

Profile of nursing diagnoses in indigenous older adults in the community: a cross-sectional study.

to describe the profile of nursing diagnoses evidenced in indigenous elderly in the community. this is a cross-sectional study, carried out with 51 indigenous elderly people of Potiguara ethnicity, through a nursing consultation. The clinical data, obtained from the consultation, were analyzed following Risner's diagnostic reasoning process and the NANDA-I Taxonomy (2018-2020). For greater accuracy, the diagnoses obtained underwent peer review by a specialist. 37 diagnoses were identified, such as Impaired dentition (98.0%), Risk for impaired skin integrity (66.7%), Chronic pain (64.7%), Risk for deficient fluid volume (54.9%), Impaired swallowing (45.1%), Impaired walking (45.1%), Disturbed sleep pattern (43.1%), Stress urinary incontinence (41.2%), Risk for falls (35.3%), and Sexual dysfunction (33.3%). the diagnoses identified were predominantly from Safety/protection domain and result from factors that negatively influence indigenous elderly's functional capacity.

Exploring body morphology and skin microcirculation in patients with critical illness

Patients in the intensive care unit are at a high risk for developing pressure injuries. Critical illness is multifaceted and not all patients are at equal risk for impaired skin integrity. Body morphology and skin microcirculatory response may reduce the skin’s tolerance level to pressure.

Effectiveness of a Pressure Ulcer Prevention Package (PUPP) for Patients Admitted in Intensive Care Units: An Experimental Study

Many critically ill patients admitted in ICUs sedated on mechanical ventilation are unable to change the position themselves. Therefore, these patients are at high risk of impaired skin integrity that leads to development of pressure ulcers. This study assessed the effectiveness of pressure ulcer prevention package in reducing the incidences of pressure ulcers among patients in ICUs. In this experimental design pre-test post-test control group study, 70 patients 35 each in experimental and control group from different ICUs of Dr RML Hospital, New Delhi were randomly allocated into two groups i.e. experimental and control groups. Experimental group received the intervention of pressure ulcer prevention package and the control group received routine skin care. Demographic and clinical data were collected by using demographic pro'Agrave;le tool, standardised skin assessment tool and pressure ulcer staging tool. All the subjects were followed every third day from admission to discharge, death and up to a maximum 20 days. Data were analysed using STATA 11.1 with the level of signi'Agrave;cance at p'lt;0.05. Descriptive and inferential statistics were used. The sacrum and then heels were the most common areas of pressure ulcers among ICU patients. Pressure ulcer prevention package was signi'Agrave;cantly effective (p'lt; 0.001) to delay the pressure ulcers-related adverse events among patients of experimental group. Pressure ulcers-related adverse events were developed earlier in control group i.e. 14 percent in experimental and 41 percent in control group. Number of pressure ulcers development were signi'Agrave;cantly (p'lt;0.001) lower in experimental group (08/35) compared to control group (20/35). The experimental group had signi'Agrave; cantly less Stage I and Stage II pressure ulcers development compared to control group (p'lt;0.001). Pressure ulcers prevention package was found to be signi'Agrave;cantly effective to reduce incidences, severity and total number of pressure ulcers among patients admitted in ICUs.

Validation of interventions for risk of impaired skin integrity in adult and aged patients.

to validate nursing interventions for the diagnosis Risk for Impaired Skin Integrity in adult and aged hospitalized patients. descriptive, quantitative study, using the content validity of interventions done by 14 specialist nurses. the specialist nurses had worked in the area for more than five years. Four (28.5%) used NANDA-I and CIPE®, three (21.4%) used NANDA-I, NIC and CIPE®, three (21.4%) used NANDA-I, NIC, NOC and CIPE® and four (28.5%) were currently working only with CIPE®. The validation analyzed 32 NIC interventions, of which 11 were priority and 21 were suggested. Of the priority interventions, five belonged to the Physiological/Complex domain, five to the Physiological/Basic domain and one to the Safety Domain. nursing interventions are essential for planning and support good practices in teaching, research and care.

Análise histórica de diagnósticos de enfermagem relacionados a feridas e lesões de pele

Objetivo: Analisar historicamente mudanças nos diagnósticos de enfermagem relacionados às feridas e lesões de pele. Método: Pesquisa documental, realizada de abril de 2017 a abril de 2019. Fizeram parte da amostra os diagnósticos de enfermagem: Integridade da Pele Prejudicada, risco da Integridade da Pele Prejudicada, Integridade Tissular Prejudicada, Risco da Integridade Tissular Prejudicada, Risco de Lesão por Pressão da Taxonomia II da NANDA de 2001 a 2018. Resultado: A principal mudança foi nas características definidoras de Integridade da pele prejudicada. A definição de Risco da integridade da pele prejudicada passou por quatro mudanças. O diagnóstico Integridade tissular prejudicada modificou a definição e fatores relacionados. Houve alteração no diagnóstico Risco de Úlcera por pressão para Risco de lesão por pressão. Conclusão: As mudanças em terminologias e acréscimo de informações nos diagnósticos foram realizadas no intuito de favorecer a sistematização da assistência de enfermagem e fomentar a melhor identificação dos diagnósticos.

Diagnósticos de enfermagem no período transoperatório: mapeamento cruzado

Objetivo: Mapear os diagnósticos de enfermagem da taxonomia NorthAmerican Nursing Diagnosis Association International (NANDA-I) em pacientes no período transoperatório. Método: Estudo do tipo transversal, documental, dos registros de enfermagem no período transoperatório de um hospital da rede suplementar de saúde do município de Niterói, Rio de Janeiro, desenvolvido por meio da ferramenta metodológica mapeamento cruzado. Resultados: Foram avaliados 65 prontuários. A maior parte da amostra foi composta de mulheres com média de idade de 50,1 anos e submetidas a cirurgias eletivas. Quanto à especialidade cirúrgica, os procedimentos mais realizados foram gerais e urológicos. Os termos mais encontrados foram bisturi elétrico, placa de bisturi, anestesia geral e entubação. Pelo painel de especialistas, obtiveram-se como diagnósticos prevalentes: risco de infecção de sítio cirúrgico (84,6%), risco de integridade da pele prejudicada (78,5%), integridade tissular prejudicada (63,1%) e risco de aspiração (58,5%). Conclusão: Os diagnósticos de enfermagem encontrados são prioritariamente de risco. Logo, carecem de identificação precoce e de intervenções para evitar danos e prevenir complicações, como o retardamento na recuperação cirúrgica.

Nursing Diagnostics in the Chagas Cardiomyopathy Carrier: Integrative Literature Review

Chagas' cardiomyopathy is a complication of Chagas' disease that presents in the cardiac form, which involves the manifestation of a clinical picture of dilated cardiomyopathy, with global left ventricular dysfunction and heart failure syndrome. In this context, the aim is to describe the Nursing Diagnosis evidenced in the literature in patients with Chagasic Cardiomyopathy. This is a descriptive and exploratory study of the Integrative Literature Review (ILR), with a qualitative approach. We searched the LILACS and PubMed databases for articles published without time limit, in Portuguese, English, and Spanish, with the descriptors: Chagasic Cardiomyopathy; Nursing Diagnosis; Nursing Care. Data were analyzed by tabulation. Three articles were sought for the sample. The following Nursing diagnoses were highlighted: Decreased Cardiac Output; Intolerance to Activity; Poor Knowledge; Sleep and Rest impaired; Anxiety; Excessive fluid volume; Risk of impaired skin integrity; and Comfort impaired. It is concluded that the diagnoses are directly related to heart failure caused by ventricular damage, and that interventions are essential for the improvement in the quality of life of patients. It is also noteworthy that the applicability of the Systematization of Nursing Care in these patients only improves the quality of service and has repercussions on patient safety, being also a way to promote the health of patients.

PEMBERIAN VCO (VIRGIN COCONUT OIL) PADA Tn. M DENGAN DIAGNOSIS MEDIS CVA INFARK DENGAN MASALAH KEPERAWATAN RISIKO KERUSAKAN INTEGRITAS KULIT DI RUANG ICU CENTRAL RUMKITAL dr. RAMELAN SURABAYA

Abstract: Ulcus decubitus is a serious dermal (skin) problem, especially for the unconscious patients with the lack of mobilization hospitalized in the ICU. It appears in the area which is localizedwith the necrotic tissues; it also usually appears on the surface of protruding bones, resulted fromthe long term pressure which increases the capillary pressure. This study was purposed to analyzethe effectiveness of the use of VCO to the patient with the risk of having ulcus decubitus in thecentral ICU of Rumkital Dr. Ramelan Surabaya (Surabaya Navy Hospital). The design used in thisstudy was case study done by investigating a problem through one case comprising of a single unit.The variable used in this study was the use of VCO to the patient with the risk of ulcus decubitus.The data were analyzed descriptively done by using inductive approach. The result of this studyconcludes that the use of VCO to Mr. M who has the risk of impaired skin integrity is effective toprevent decubitus.

DIAGNÓSTICOS, INTERVENÇÕES E RESULTADOS ESPERADOS DE ENFERMAGEM PARA PACIENTES COM HIV/AIDS: REVISÃO INTEGRATIVA

Objective: To identify in the scientific literature nursing diagnoses for patients with HIV/AIDS. Methods: This was an integrative review of literature carried out in the databases Virtual Health Library, Lilacs, SciELO, PubMED, CINAHL, between June and July 2014. The following descriptors were used: Acquired Immune Deficiency Syndrome, Safe Sex, HIV, Nursing Diagnosis and Nursing Care. After a refined search, the articles were selected based on inclusion and exclusion criteria and underwent analysis and standardization. A total of four articles were selected in the final review. These articles followed the nomenclature adopted by the North American Nursing Diagnosis Association - NANDA for the establishment of nursing diagnoses. Results: The nursing diagnoses were: Ineffective breathing pattern; risk of impaired skin integrity; impaired religiosity; defensive coping characterized by denial of problems or obvious weaknesses and refusal to get help; risk of powerlessness related to disease and inadequate coping patterns. A total of 24 interventions and 13 expected outcomes were established. Conclusion: Nursing diagnosis guide the development of interventions and outcomes prioritizing the needs of the patient with HIV/AIDS. With this, we note that the nursing process constitutes an essential instrument for effectiveness of an organized nursing care based on basic human needs. DESCRIPTORS Acquired Immunodeficiency Syndrome. Safe Sex. HIV. Nursing Diagnosis.Nursing Care.

Nursing Care in Polycythemia Vera: A Review Article

Background: Polycythemia vera (PV) is a chronic myeloproliferative neoplasm, which is a threat to life. Teamwork is needed during the process of treatment and care of patients suffering from PV, which is a chronic illness. Especially, important roles fall to the nurses within the team. Objective: The purpose of this article is to assess the symptoms in connection with PV and the treatment and the difficulties which have been experienced, in accordance with the System for the Categorisation of Nursing Diagnoses of the North American Nursing Diagnosis Association (NANDA) and present possible nursing diagnoses and the management of symptoms according to these diagnoses. Methods: This review article was carried out by have been scanned with the search terms PV, care and nursing in PubMed databases, CINAHL®, Ebsco Academic Search Complete, Scopus and Scholar Google databases. The approaches directed at the nursing diagnoses which have been determined in the article, are based on the papers from peer-reviewed publications, books, guidelines and the recommendations made by medical professionals. Results and conclusion: The important nursing diagnosis related with PV are altered gas exchange, altered tissue perfusion, fatigue, high risk of injury, high risk of infection, deterioration of comfort (itching), high risk of impaired skin integrity and pain. It was not possible to find any randomized controlled studies on this subject. It is recommended that these diagnosis and differences are taken into account in nursing interventions. Nurses need to use a patient centred approach in the administration of PV, in order to assess the patients, plan care and achieve the self-management of the disease with the patient, who has been empowered with knowledge.

Nursing Diagnoses of the Domain Safety/Protection and Socioeconomic and Clinical Aspects of Critical Patients

Objective: The objective is to correlate the nursing diagnoses of the domain Safety/Protection of NANDA-I in critically ill patients with sociodemographic and clinical data. Method: A cross-sectional study with 86 individuals was conducted, from October 2013 to May 2014 in the Intensive Care Unit of a university hospital in northeastern Brazil, through a formal interview and physical examination. Results: It was possible to identify a total of 20 significant statistical associations, and 15 were clinically justified by the literature, namely: risk for aspiration and reason for admission; impaired dentition and age; risk for peripheral neurovascular dysfunction and sex and comorbidity; skin integrity and comorbidity; risk for impaired skin integrity and gender and reason for admission; impaired tissue integrity and gender and reason for admission; risk for perioperative positioning injury and reason for admission; risk for thermal injury and age and comorbidity; delayed surgical recovery and reason for admission; risk for poisoning and years of schooling; and risk for imbalanced body temperature and age. Conclusions: By understanding the relationship between customers’ answers and the sociodemographic and clinical profile, positive health outcomes can be achieved in particular in the prevention of risks facing vulnerability characteristics, providing greater safety and protection for the critical customer.

Diagnósticos de enfermagem mais frequentes em uma unidade de terapia intensiva pediátrica

Aim: to identify the ten most frequent nursing diagnosis in hospitalized patients in a Pediatric Intensive Care Unit. Method: cross-sectional study with 30 patients in a Pediatric Intensive Care Unit. The data were collected during the January and February 2013. Results: the nursing diagnosis, according to the taxonomy of North American Nursing Diagnosis Association: Risk of infection (86,67%), Dysfunctional gastrointestinal motility (60%), Ineffective airway clearance (53,3%), Risk of impaired skin integrity (40%), Risk of vascular trauma (40%), Risk of electrolyte imbalance (36,67%), Impaired spontaneous ventilation (36,67%), Acute pain (33,3%), Constipation (33,3%), Impaired skin integrity (26,67%). Conclusions: the identification of the nursing diagnosis can contribute to implementation of the Nursing Care Systematization at the Pediatric Intensive Care Unit, allowing that assistance to be targeted and specified to actual and potential health problems of the subject to be cared

The effect of 2 adhesive products on skin integrity used for fixation of hip and knee surgical dressings: a randomized controlled trial.

The aim of this study was to compare effects of 2 adhesive products, a nonwoven porous adhesive bandage (NPAB) and transparent film adhesive bandage (TFAB), on skin integrity for fixation of hip and knee surgical dressings. A prospective, randomized study was conducted on 300 patients who underwent hip and knee surgery (arthroplasty, fixation of fractures, tumor operations, etc). Participants were randomized into 2 equal groups according to the applied surgical dressing fixation product (NPAB or TFAB). Skin changes (edema, erythema, blister, peeling of blister, mechanical peeling, and maceration), drying of incision, serous discharge, and early infection symptoms were evaluated. The skin integrity was found to be impaired in 4.0% (n = 6) of the 150 NPAB patients and in 10.7% (n = 16) of the 150 TFAB patients (P = .02). Logistic regression analysis showed that the risk of impaired skin integrity increased 2.5-fold when TFAB was applied (P = .03). The NPAB was associated with a reduced likelihood of impaired skin integrity following hip and knee surgery.

Assessment of nursing care using indicators generated by software.

OBJECTIVE: to analyze the efficacy of the Nursing Process in an Intensive Care Unit using indicators generated by software. METHOD: cross-sectional study using data collected for four months. RNs and students daily registered patients, took history (at admission), performed physical assessments, and established nursing diagnoses, nursing plans/prescriptions, and assessed care delivered to 17 patients using software. Indicators concerning the incidence and prevalence of nursing diagnoses, rate of effectiveness, risk diagnoses, and rate of effective prevention of complications were computed. RESULTS: the Risk for imbalanced body temperature was the most frequent diagnosis (23.53%), while the least frequent was Risk for constipation (0%). The Risk for Impaired skin integrity was prevalent in 100% of the patients, while Risk for acute confusion was the least prevalent (11.76%). Risk for constipation and Risk for impaired skin integrity obtained a rate of risk diagnostic effectiveness of 100%. The rate of effective prevention of acute confusion and falls was 100%. CONCLUSION: the efficacy of the Nursing Process using indicators was analyzed because these indicators reveal how nurses have identified patients' risks and conditions, and planned care in a systematized manner.