00248 Risk Of Tissue Integrity Deterioration

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: 00248
Nanda label: risk of tissue integrity deterioration
Diagnostic focus: tissue integrity
Approved 2013 • Revised 2017, 2020 • Evidence level 3.2

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « risk of tissue integrity deterioration ” is defined as: susceptible Bone, cartilage, joint capsule and/or ligament, which can compromise health.

Risk factors

External factors

  • Excretions
  • Humidity
  • Hyperthermia
  • Hypothermia
  • Inadequate knowledge of the caregiver (a) on the maintenance of tissue integrity
  • Inadequate knowledge of the caregiver (a) on the protection of tissue integrity
  • Inappropriate use of chemical agent
  • Bone prominence pressure
  • Psychomotor agitation
  • Secretions
  • Hear forces
  • Friction on the surface
  • Use of bedding with insufficient moisture absorption capacity

Internal factors

  • Body mass index above the normal range according to age and sex
  • Body mass index below the normal range according to age and sex
  • Decrease in flicker frequency
  • Decrease in physical activity
  • Liquid imbalance
  • deterioration of physical mobility
  • Postural balance deterioration
  • Inappropriate adhesion to the incontinence treatment regime
  • Inadequate management of the blood glucose level
  • Inappropriate knowledge about the maintenance of tissue integrity
  • Inappropriate knowledge about the restoration of tissue integrity
  • Inappropriate care of ostomy
  • Malnutrition
  • Psychogenic factor
  • Automutilation
  • smoking
  • Inappropriate use of substances

Risk population

  • Homeless people
  • People with extreme ages
  • People exposed to extreme environmental temperatures
  • People exposed to a high voltage power supply
  • People participating in contact sports
  • People participating in winter sports
  • People with family history of bone fracture
  • People with a history of bone fracture

Associated problems

  • Anemia
  • Autistic spectrum disorder
  • Cardiovascular disease
  • Chronic neurological problems
  • Severe condition
  • Decrease in the level of consciousness
  • Decrease in serum albumin level
  • Decrease in tissue oxygenation
  • Decrease in tissue perfusion
  • Hemodynamic instability
  • Immobilization
  • Intellectual disability
  • Medical devices
  • Metabolic diseases
  • Peripheral neuropathy
  • Pharmacological preparations
  • Sensitivity disorders
  • Surgical procedures