The skin serves as the body’s primary defense, preventing pathogens from causing infections and illness. When this protective barrier is compromised due to injuries like cuts, abrasions, ulcers, surgical incisions, and wounds, it creates an entry point for bacteria, increasing the risk of infections. For nurses, a thorough understanding of how to assess, prevent, manage, and educate patients about impaired skin integrity is crucial for optimal patient care.
In this article, we will explore the essential aspects of impaired skin integrity, focusing on its causes, signs and symptoms, assessment techniques, nursing interventions, and care plans. This guide aims to provide a comprehensive resource for nurses to effectively address this common nursing diagnosis.
Causes of Impaired Skin Integrity
Impaired skin integrity can arise from a variety of factors, broadly categorized as internal and external causes. Understanding these causes is the first step in preventing and managing skin breakdown.
Internal Factors:
- Extremes in Age: Both very young and older adults have more fragile skin that is susceptible to damage.
- Cognitive Impairment: Patients with cognitive deficits may be unable to communicate discomfort or reposition themselves, increasing pressure injury risk.
- Paralysis: Loss of mobility due to paralysis significantly increases the risk of pressure injuries as patients cannot independently relieve pressure points.
- Physical Immobilization/Bedrest: Prolonged bed rest or immobility reduces circulation and increases pressure on specific skin areas, leading to breakdown.
External Factors:
- Hyperthermia: Elevated body temperature can lead to increased perspiration and moisture, predisposing the skin to maceration and breakdown.
- Hypothermia: Low body temperature can reduce circulation and tissue oxygenation, making the skin more vulnerable to injury.
- Radiation: Radiation therapy can damage skin cells, leading to dryness, irritation, and impaired skin integrity in the treated area.
- Chemicals: Exposure to harsh chemicals can cause skin irritation, burns, and breakdown.
- Surgery: Surgical incisions disrupt skin integrity and can be a site for infection if not properly cared for.
- Wounds: Existing wounds, regardless of cause, represent an area of impaired skin integrity that requires specific care to promote healing.
- Moisture/Secretions: Excessive moisture from sweat, urine, stool, or wound drainage can macerate the skin and increase the risk of breakdown.
- Shearing/Friction/Pressure: These mechanical forces can damage the skin, particularly over bony prominences, leading to pressure injuries.
Signs and Symptoms of Impaired Skin Integrity
Recognizing the signs and symptoms of impaired skin integrity is vital for early intervention and prevention of further complications. These manifestations can be subjective, reported by the patient, or objective, observed by the nurse during assessment.
Subjective Symptoms (Patient Reports):
- Pain: Discomfort or pain at the site of skin breakdown is a common complaint.
- Itching: Pruritus or itching may occur due to skin irritation or dryness.
- Numbness: Patients may report a loss of sensation or numbness in the affected skin and surrounding areas, especially in cases of nerve damage.
Objective Signs (Nurse Assesses):
- Changes to Skin Color: This can include erythema (redness), bruising, or blanching (pale appearance) indicating compromised blood flow or inflammation.
- Warmth to Skin: Increased temperature in a localized area may suggest inflammation or infection.
- Swelling to Tissues: Edema or swelling around the affected skin can indicate tissue damage or fluid accumulation.
- Observed Open Areas or Breakdown: This includes visible breaks in the skin, excoriation (superficial skin abrasion), or deeper wounds like ulcers.
Expected Outcomes for Impaired Skin Integrity
The primary goals of nursing care for patients with impaired skin integrity are focused on promoting healing, preventing complications, and educating patients on self-care. Expected outcomes include:
- Patient will maintain intact skin integrity: Preventing new areas of skin breakdown.
- Patient will experience timely healing of wounds without complications: Promoting wound closure and avoiding infection or delayed healing.
- Patient will demonstrate effective wound care: Patients or caregivers will be able to perform appropriate wound care techniques.
- Patient will verbalize proper prevention of pressure injuries: Patients will understand and implement strategies to prevent future skin breakdown.
Nursing Assessment for Impaired Skin Integrity
A thorough nursing assessment is the foundation of effective care for impaired skin integrity. It involves gathering both subjective and objective data to identify risk factors, current skin condition, and guide appropriate interventions.
1. Conduct a Thorough Skin Assessment: Perform a complete head-to-toe skin examination upon admission, during unit transfers, and at least once per shift. Pay close attention to high-risk areas for skin breakdown, such as heels, sacrum, elbows, and hips. This routine assessment is crucial for early detection and prevention of skin breakdown.
2. Utilize Braden Skin Assessment Scale: Employ the Braden Scale, an evidence-based tool, to assess a patient’s risk for developing pressure injuries. This scale evaluates six key criteria:
- Sensory Perception: Ability to sense and respond to discomfort related to pressure.
- Moisture: Degree of skin exposure to moisture.
- Activity: Level of physical activity.
- Mobility: Ability to change and control body position.
- Nutrition: Usual food intake pattern.
- Friction and Shear: Resistance encountered when moving the patient in bed or chair.
Note: The Braden Scale score ranges from 6 to 23, with lower scores indicating a higher risk of pressure injury development. Frequency of Braden Scale assessment is often dictated by institutional policy, but nurses should also use it whenever they suspect a risk of skin breakdown.
3. Assess Circulatory Status: Evaluate skin circulation, sensation, and turgor. Poor skin turgor (decreased elasticity), diminished sensation (potential nerve damage), and compromised circulation (indicated by skin discoloration, coolness, or weak pulses) increase the risk of tissue injury.
4. Assess Activity Level and Mobility: Observe the patient’s ability to ambulate and reposition themselves in bed or chair. Patients with limited mobility or those who require restraints are at higher risk for skin breakdown due to sustained pressure and reduced blood flow.
5. Determine Risk Related to Moisture: Assess factors contributing to skin moisture, such as excessive perspiration, incontinence (urinary or fecal), and wound drainage. Prolonged exposure to moisture significantly increases the risk of skin maceration and breakdown.
6. Evaluate Self-Care Ability: Determine the patient’s capacity for self-care, particularly regarding incontinence management and hygiene. Patients who are incontinent and unable to manage their hygiene independently require more frequent monitoring and assistance to maintain skin dryness and cleanliness.
7. Describe the Wound Thoroughly: Accurate documentation of wounds and skin breakdown is essential for tracking healing progress and treatment effectiveness. Record wound location, size (length, width, depth), stage (if pressure injury), drainage characteristics (color, amount, odor), periwound skin condition, presence of undermining or tunneling, and pain level. Consider taking photographs for visual documentation and comparative purposes over time.
8. Assess Nutrition and Hydration Status: Monitor the patient’s nutritional intake and fluid balance. Adequate hydration and nutrition, especially protein intake, are crucial for tissue repair and wound healing. Consult with a dietitian as needed.
9. Assess Stoma and Ostomy Sites: For patients with ostomies, assess the stoma site for proper healing, color (should be pink to red and moist), and surrounding skin integrity. Evaluate the fit and effectiveness of the ostomy appliance. A wound care specialist should be involved in the assessment and management of stomas.
Nursing Interventions for Impaired Skin Integrity
Nursing interventions are crucial for both preventing and treating impaired skin integrity. These actions aim to minimize risk factors, promote skin healing, and prevent complications.
1. Implement Prescribed Wound Care Protocols: Apply appropriate wound care protocols based on the type, location, and severity of the wound. This may include cleansing, debridement, dressing application, and topical treatments as ordered by the physician or wound care specialist and according to facility policies.
2. Position Patient for Comfort and Pressure Relief: Reposition patients, especially those with limited mobility, at least every two hours or more frequently as needed and according to facility protocols. Use positioning aids like pillows and wedges to protect bony prominences (elbows, knees, hips, heels, sacrum) and relieve pressure. A turn clock can be a helpful tool to remind staff of repositioning schedules.
3. Ensure Adequate Skin Perfusion: Utilize pressure-redistributing support surfaces, such as specialized mattresses and cushions, to minimize pressure on bony prominences and promote blood flow to the skin.
4. Maintain Skin Dryness and Cleanliness: Keep the patient’s skin clean and dry, especially in areas prone to moisture accumulation (perineal area, skin folds). Promptly address incontinence, perspiration, and wound drainage. Use gentle cleansers and avoid harsh soaps that can dry the skin.
5. Alleviate Pressure with Support Surfaces: Employ pressure-relieving devices such as low-air loss mattresses, air mattresses, wedge pillows, waffle boots, and gel overlays on chairs and beds. These devices help redistribute weight and reduce pressure on vulnerable skin areas.
6. Promote Optimal Nutrition and Hydration: Encourage adequate fluid intake and a balanced diet rich in protein, vitamins, and minerals to support tissue repair and wound healing. Collaborate with a dietitian to develop individualized nutrition plans as needed.
7. Protect Skin from Further Injury: Implement measures to protect the skin from friction, shear, and further trauma. This may include using protective dressings, ensuring proper lifting and transferring techniques, and advising patients to wear socks and non-slip footwear, especially for patients with compromised neurovascular status like those with diabetes.
8. Consult with Wound/Ostomy Specialist: Collaborate with a wound care or ostomy specialist for complex wounds, stoma care, and when specialized expertise is needed. These specialists can provide valuable recommendations for wound care protocols, product selection, and patient education.
9. Minimize Skin Irritation: Use barrier creams, pastes, or powders to protect skin exposed to moisture or irritants, such as around stomas or in areas of incontinence. Adhesive removers can facilitate pouch removal for ostomy patients without causing skin trauma.
10. Manage Ostomy Pouching Systems: Educate patients and caregivers on the proper techniques for emptying, changing, and fitting ostomy pouches. Correct sizing of the adhesive wafer and proper pouch application are crucial to prevent leaks and skin irritation around the stoma (peristomal skin). Empty ostomy pouches when they are one-third to one-half full to prevent excessive weight and potential detachment from the skin.
Nursing Care Plans for Impaired Skin Integrity
Nursing care plans provide a structured framework for organizing and delivering patient care. They prioritize assessments and interventions to achieve both short-term and long-term goals related to impaired skin integrity. Here are examples of nursing care plans addressing various aspects of impaired skin integrity:
Care Plan #1: Impaired Skin Integrity related to Immobility
Diagnostic Statement: Impaired skin integrity related to immobility as evidenced by stage 2 pressure ulcer to the sacrum.
Expected Outcomes:
- Patient will demonstrate improvement in pressure ulcer stage from stage 2 to stage 1 within 2 weeks of nursing interventions.
- Patient will maintain clean and dry skin at all times.
- Patient will verbalize understanding and cooperation with wound care regimen within 24 hours.
- Patient will list three methods to prevent pressure ulcers within 24 hours.
Assessment:
- Assess skin and wounds regularly (at least once per shift): Monitor skin at risk for breakdown and existing wounds for signs of worsening, such as increased redness or drainage. Measure wounds weekly to track healing progress.
- Determine patient’s mobility level: Assess the patient’s ability to move and reposition independently to identify the level of assistance required.
- Assess need for positioning devices: Evaluate the need for pillows, wedges, or specialized mattresses to offload bony prominences based on patient size and mobility.
Interventions:
- Perform wound care per guidelines and orders: Implement prescribed wound care protocols based on wound type and location to promote healing and prevent infection.
- Reposition patient and support bony prominences: Turn and reposition the patient at least every 2 hours. Use pillows and devices to support bony prominences and promote skin perfusion.
- Keep skin clean and dry: Assess for incontinence and perspiration. Keep bed linens, clothing, and perineal area clean and dry to minimize skin irritation.
- Utilize appropriate support surfaces: Employ pressure-redistributing mattresses and cushions to alleviate pressure.
- Encourage optimal nutrition and hydration: Promote adequate fluid and protein intake to support wound healing.
Care Plan #2: Impaired Skin Integrity related to Diabetic Neuropathy
Diagnostic Statement: Impaired skin integrity related to decreased skin sensation secondary to diabetic neuropathy as evidenced by redness and an open area to the left lower leg.
Expected Outcomes:
- Patient will exhibit intact skin on lower extremities by discharge.
- Patient will list three methods to prevent skin infection within 24 hours.
- Patient will maintain adequate skin perfusion as evidenced by controlled blood glucose levels.
- Patient will verbalize understanding of the importance of daily skin inspection within 24 hours.
Assessment:
- Assess skin for signs of infection: Monitor for redness, purulent drainage, warmth, foul odor, and swelling, which are indicators of infection.
- Determine skin perfusion: Assess for signs of decreased circulation and sensation in the lower extremities common in diabetic neuropathy.
- Monitor blood glucose levels: Regularly check blood glucose levels as hyperglycemia impairs wound healing and increases infection risk.
Interventions:
- Control blood glucose levels: Maintain blood glucose within the target range to minimize nerve damage, promote wound healing, and reduce infection risk.
- Educate on diabetic neuropathy and daily skin checks: Teach the patient about diabetic neuropathy and the importance of daily foot and skin inspections to identify injuries early.
- Ensure foot protection: Advise the patient to wear protective footwear at all times to prevent foot injuries due to decreased sensation.
Care Plan #3: Impaired Skin Integrity related to Surgical Incision and Stoma Creation
Diagnostic Statement: Impaired skin integrity related to surgical incision and stoma creation to the abdomen.
Expected Outcomes:
- Patient will verbalize understanding of stoma skin care and prevention of irritation within 24 hours.
- Patient will exhibit a moist and pink stoma at discharge.
- Patient will list three methods to protect the stoma from skin breakdown within 24 hours.
- Patient will demonstrate proper ostomy pouch fitting and emptying techniques within 24 hours.
Assessment:
- Determine indication for surgery/stoma: Understand the underlying medical condition that necessitated stoma creation to provide appropriate care and education.
- Assess incision and stoma: Evaluate the surgical incision and stoma site for healing, color, swelling, and protrusion.
- Determine patient’s dietary intake: Assess nutritional status and dietary needs as nutrition plays a vital role in wound and stoma healing.
Interventions:
- Collaborate with wound/ostomy specialist: Consult with a specialist for expert guidance on stoma care, appliance selection, and patient education.
- Create meal plans with the patient: Educate the patient on dietary modifications to manage ostomy output and prevent complications like diarrhea.
- Minimize skin irritation around stoma: Advise on the use of barrier pastes and powders to protect peristomal skin from irritation and leakage.
- Educate on ostomy pouch management: Teach proper techniques for fitting, emptying, and changing the ostomy pouching system to prevent complications and maintain skin integrity.
Care Plan #4: Impaired Skin Integrity related to Burn Wounds
Diagnostic Statement: Impaired skin integrity related to burn wounds.
Expected Outcomes:
- Patient will demonstrate skin restoration as evidenced by tissue regeneration within the expected healing timeframe.
- Patient will maintain intact wound dressing at all times.
- Patient will verbalize cooperation with wound care regimen.
- Patient will list three methods to prevent skin infection in burn wounds within 24 hours.
Assessment:
- Assess burn wound severity: Determine the depth and extent of the burn injury to guide treatment and assess infection risk.
- Determine burn degree: Classify the burn as first, second, third, or fourth degree to understand the level of tissue damage.
- Assess patient knowledge of wound dressing: Evaluate the patient’s understanding and expectations regarding burn wound care and dressing changes.
Interventions:
- Apply wound dressing: Cover burn wounds with appropriate dressings using aseptic technique to prevent infection and promote healing.
- Cleanse the wound regularly: Perform wound cleansing and debridement to remove debris and exudate, promoting wound healing.
- Promote new skin growth: Implement strategies to support skin regeneration, which may include specialized dressings or skin tissue engineering techniques.
- Encourage patient compliance with wound dressing changes: Provide pain management and education to enhance patient cooperation with dressing changes and promote healing.
Care Plan #5: Impaired Skin Integrity related to Radiation Therapy
Diagnostic Statement: Impaired skin integrity related to radiation therapy as evidenced by erythema and reports of irritation to the axillary area.
Expected Outcomes:
- Patient will verbalize two interventions to prevent skin irritation from radiation therapy.
- Patient will report signs of worsening skin breakdown (peeling, open areas, drainage) to the nurse promptly.
Assessment:
- Assess skin prior to each treatment: Monitor skin integrity before each radiation therapy session to detect early signs of breakdown or infection.
- Assess patient understanding of skin reactions: Evaluate the patient’s knowledge of expected and abnormal skin reactions to radiation therapy.
Interventions:
- Moisturize after treatments: Instruct the patient to apply fragrance-free, lanolin-free moisturizers to the treated area after each radiation session to keep skin hydrated.
- Keep skin clean and dry: Advise the patient to cleanse the treated area gently with warm water and mild soap, ensuring it is thoroughly dried.
- Avoid abrasive cleaners: Instruct the patient to avoid harsh soaps, antibacterial cleansers, and alcohol-based products that can dry or irritate the skin.
- Wear loose clothing and comfortable bra: Recommend loose-fitting, breathable cotton clothing and a soft bra without underwire to minimize friction and irritation.
- Avoid direct sun exposure: Advise the patient to protect the treated area from direct sunlight to prevent further irritation and hyperpigmentation.
By utilizing these comprehensive nursing care plans and interventions, nurses can effectively manage and prevent impaired skin integrity, promoting patient comfort, healing, and overall well-being.
