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Excessive and continuous skin moisture can pose a risk to compromise the integrity of the skin by causing the skin tissue to become macerated and therefore be at risk for epidermal erosion. So this category assesses the degree of moisture the skin is exposed to.
The shared objective of treatment and prevention is maintenance and/or restoration of the integrity and healthy functionality of skin surrounding the wound. Main treatment and prevention strategies include the following: Holistic wound assessment that includes periwound assessment. [1] Elimination of factors causing moisture-associated skin damage.
Periwound skin damage caused by excessive amounts of exudate and other bodily fluids can perpetuate the non-healing status of chronic wounds. Maceration, excoriation, dry (fragile) skin, hyperkeratosis, callus and eczema are frequent problems [17] that interfere with the integrity of periwound skin. They can create a gateway for infection as ...
The second two levels form a taxonomy in which each intervention is grouped into 27 classes, and each class is grouped into six domains. An intent of this structure is to make it easier for a nurse to select an intervention for the situation, and to use a computer to describe the intervention in terms of standardized labels for classes and domains.
These interventions aim to address the four areas of wellness (energy conservation, structural integrity, personal integrity and social integrity). [ 5 ] [ 6 ] [ 7 ] Evaluation- Evaluation of the interventions aimed at supporting the nurse's hypotheses seek to assess the client's response to the interventions.
Diabetic foot ulcer is a breakdown of the skin and sometimes deeper tissues of the foot that leads to sore formation. It is thought to occur due to abnormal pressure or mechanical stress chronically applied to the foot, usually with concomitant predisposing conditions such as peripheral sensory neuropathy, peripheral motor neuropathy, autonomic neuropathy or peripheral arterial disease. [1]
Timing is important to wound healing. Critically, the timing of wound re-epithelialization can decide the outcome of the healing. [11] If the epithelization of tissue over a denuded area is slow, a scar will form over many weeks, or months; [12] [13] If the epithelization of a wounded area is fast, the healing will result in regeneration.
The nursing process is a modified scientific method which is a fundamental part of nursing practices in many countries around the world. [1] [2] [3] Nursing practise was first described as a four-stage nursing process by Ida Jean Orlando in 1958. [4] It should not be confused with nursing theories or health informatics. The diagnosis phase was ...