#28

28) List the nursing diagnoses for the client with impaired skin integrity.
Risk for Impaired Skin Integrity related to incontinence and immobility/At risk for skin being adversely altered.
Impaired Skin Integrity (stage II pressure ulcer)related to friction/Altered epidermis and/or dermis
Kozier pg 868
Impaired Skin Integrity
Related to:
mechanical factors (pressure, shear, friction, moisture)
altered circulation
altered sensation
radiation
medications
As evidenced by:
disruption of skin surface (incision, rash, excoriation, open wound(s) (specify type, location)

handout from Mary Lou