Nursing Care Plan for Acne: Impaired Skin Integrity

Nursing Diagnosis: Impaired Skin Integrity

Acne

Acne, a common skin condition affecting millions worldwide, is more than just a cosmetic concern. This article explores the intricacies of acne, shedding light on its causes, available treatments, and preventive measures to promote clearer, healthier skin.

Causes of Acne:

1. Excess Sebum Production: Overproduction of sebum, the skin's natural oil, can lead to clogged pores, creating an ideal environment for acne development.
2. Clogged Hair Follicles: When dead skin cells and sebum accumulate in hair follicles, they can form comedones (whiteheads and blackheads), providing a breeding ground for acne-causing bacteria.
3. Bacterial Infection: Propionibacterium acnes, a type of bacteria, thrives in clogged pores, causing inflammation and contributing to the development of inflammatory acne.
4. Hormonal Fluctuations: Changes in hormonal levels, especially during puberty, menstruation, pregnancy, or when using certain contraceptives, can trigger acne breakouts.
5. Genetic Factors: A family history of acne may increase an individual's susceptibility to developing the condition.

Prevention of Acne:

1. Regular Cleansing: Gentle cleansing with a mild, non-comedogenic cleanser helps remove excess oil, dirt, and dead skin cells from the skin's surface.
2. Avoiding Skin Irritants: Harsh skincare products, excessive scrubbing, and picking at acne lesions can exacerbate inflammation and worsen acne. Choose products labeled as "non-comedogenic" and be gentle with your skin.
3. Healthy Diet: A well-balanced diet rich in fruits, vegetables, and whole grains can contribute to overall skin health. Some studies suggest a link between dairy consumption and acne, so individual dietary choices may impact skin condition.
4. Hydration: Drinking an adequate amount of water helps maintain skin hydration and may contribute to clearer skin.
5. Stress Management: Chronic stress can exacerbate acne, so practicing stress-reducing activities like meditation, yoga, or deep breathing can be beneficial.

 

Impaired skin integrity

 

Impaired skin integrity refers to a condition in which the skin's protective barrier is compromised, leading to a breakdown of its structural integrity and functionality. This impairment can manifest in various forms, including wounds, lesions, or alterations in the skin's texture and appearance. The causes of impaired skin integrity are diverse, ranging from pressure and friction-related injuries to moisture-related damage and skin tears.

Understanding the concept involves recognizing that the skin serves as the body's first line of defense against external threats such as infections, chemicals, and physical trauma. When the skin's protective barrier is compromised, it becomes more susceptible to damage and may lose its ability to prevent the entry of harmful microorganisms.

Assessment of impaired skin integrity involves careful observation and documentation of changes in the skin, including color, temperature, texture, and the presence of wounds or lesions. Various scales and tools, such as the Braden Scale or Norton Scale, may be used to assess the risk of pressure ulcers and guide preventive measures.

Impaired Skin Integrity

Altered epidermis and/or dermis: Invasion of body structures, destruction of skin layers (dermis), and disruption of skin surface (epidermis).


Nursing Diagnosis: Impaired Skin Integrity related to the destruction of skin tissue characterized by papules, pustules, nodes and lesions.

Nursing Interventions for Acne :

1. Encourage clients to avoid all forms of friction (touched, scratched by hand) on the skin.
Rational: Preventing the spread of bacteria that can worsen the infection in the skin lesions.

2. Instruct the patient to be able to treat the skin with a clean and correct.
Rational: the right skin care reduces the risk of accumulation of dirt on the skin.

3. Motivation of patients to keep taking the drugs and foods that contain enough nutrients.
Rational: To expedite the healing process.

4. Observations of erythema and palpated for warmth around the area.
Rational: The warmth is a sign of infection.

5. Collaboration of topical antibiotics.
Rational: To inhibit the growth of bacteria

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Impaired Skin Integrity - Nursing Diagnosis Interventions for Marasmus

Marasmus is a form of protein deficiency which can cause fatigue, wasting of the muscles, low energy levels and weight loss. Like kwashiorkor, it can also weaken the immune system and increase the risk of infection amongst sufferers.

Marasmus can occur at any age, but that is often found in infants who are not getting enough milk and are not fed often attacked his successor or diarrhea. Marasmus may also occur due to various other diseases such as infections, gastrointestinal disorders or congenital heart disease, malabsorption, metabolic disorders, chronic kidney disease and disorders of the central nervous

The main causes of marasmus are less calorie protein that may occur due to: insufficient diet, eating habits are not exactly like the parent-child relationship with a disturbed, because of metabolic disorders, or congenital malformations. (Nelson, 1999).



Nursing Diagnosis Impaired Skin Integrity related to changes in nutritional status.

NOC: Tissue Integrity: Skin and mucous membranes.

Expected outcomes are:

1. A good skin integrity can be maintained.
2. No injuries / lesions on the skin.
3. Good tissue perfusion.
4. Show understanding of the process of skin repair and prevent recurring injury.
5. . Able to protect skin and keep skin moist and natural treatments.

Rating Scale:

1. do not ever show
2. rarely show
3. sometimes shows
4. often show
5. always show

NIC: Tissue Integrity: Skin and mucous.
Nursing Interventions - Impaired Skin Integrity for Marasmus

1. Monitor the skin will turn pink.
2. Apply lotion to a depressed area.
3. Mobilization of the patient every 2 hours.
4. Keep your skin clean and dry to keep them clean.

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Impaired Skin Integrity Nanda Nursing Diagnosis - Stevens-Johnson Syndrome (SJS)

Stevens Johnsons Syndrome is a dangerous problem of the skin. It is thought to be a hypersensitivity complex affecting the skin and the mucous membranes.

Stevens Johnson Syndrome (SJS) is a severe and deadly allergic reaction to certain drugs, some proscription and some over the counter, which causes the severe burning of skin and mucosal membranes from the inside out. 15% of people who develop Stevens Johnson Syndrome will die as a direct result. Many drugs which have been known to cause SJS do not have warning labels notifying users about the very real danger of Stevens Johnson Syndrome.

The skin rash of SJS consists of erythematous (red) papules, vesicles, bullae. There may also be iris lesions. The mucosal lesions include conjunctivitis as well as oral and genital ulcers. The most frequent complications of SJS are keratitis, uveitis, and perforation of the globe of the eye all of which may result in permanent visual impairment.

Nanda Nursing Diagnosis : Impaired skin integrity related to inflammatory dermal and epidermal

Expected Outcomes:

Shows the skin and skin tissue intact.

Intervention:

1. Observation of skin turgor circulation daily notes and sensory as well as other changes that occur.
Rational: determining a baseline by which changes in status can be compared and appropriate intervention

2. Use a thin clothing and soft loom.
Rational: reduce irritation and pressure from the suture line of clothes, leave the incision open to air increases the healing process and reduce the risk of infection

3. Keep loom is used.
Rationale: to prevent infection

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