The skin serves as the body’s first line of defense, a vital barrier against external pathogens that can cause infection and disease. When this protective layer is compromised due to various factors such as cuts, abrasions, ulcers, surgical incisions, or wounds, the body becomes vulnerable to bacterial invasion and subsequent infections. For nurses, a thorough understanding of how to assess, prevent, manage, and educate patients about risk for impaired skin integrity is paramount in delivering effective and holistic patient care.
In this article, we will delve into the critical aspects of risk for impaired skin integrity as a nursing diagnosis, providing a detailed care plan to guide nurses in their practice.
Causes of Risk for Impaired Skin Integrity
Several factors can contribute to or heighten the risk for impaired skin integrity. These causes are broadly categorized into internal and external factors:
Internal Factors:
- Extremes in Age: Both very young and elderly individuals have more delicate and vulnerable skin. Infants have thinner skin that is easily irritated, while older adults experience age-related skin changes such as decreased elasticity, reduced collagen, and diminished subcutaneous fat, making their skin more susceptible to injury and slower to heal.
- Cognitive Impairment: Patients with cognitive deficits may be unable to communicate discomfort, reposition themselves, or adhere to preventive measures, increasing their risk for impaired skin integrity.
- Paralysis: Immobility due to paralysis significantly increases pressure on certain areas of the body, restricting blood flow and leading to potential skin breakdown.
- Nutritional Deficiencies: Inadequate intake of essential nutrients, particularly protein, vitamins, and minerals, impairs the skin’s ability to repair and regenerate, making it more vulnerable to damage.
- Dehydration: Insufficient fluid intake can lead to dry, brittle skin that is more prone to cracking and injury.
- Underlying Medical Conditions: Certain diseases like diabetes mellitus, peripheral vascular disease, and autoimmune disorders can compromise circulation, sensation, and the skin’s healing capabilities, elevating the risk for impaired skin integrity.
External Factors:
- Hyperthermia: Elevated body temperature can lead to increased perspiration, causing skin maceration and breakdown, particularly in skin folds.
- Hypothermia: Conversely, low body temperature can reduce blood flow to the skin, making it pale, cold, and more susceptible to damage.
- Radiation: Exposure to radiation, whether from therapeutic treatments or environmental sources, can cause skin damage ranging from mild erythema to severe burns, increasing the risk for impaired skin integrity.
- Chemicals: Exposure to harsh chemicals, irritants, and allergens can cause skin irritation, inflammation, and breakdown.
- Physical Immobilization/Bedrest: Prolonged pressure on bony prominences due to immobility is a major risk factor for pressure ulcers and impaired skin integrity.
- Surgery: Surgical incisions disrupt skin integrity and create a portal of entry for pathogens, requiring meticulous wound care to prevent infection and promote healing.
- Wounds: Pre-existing wounds, whether acute or chronic, compromise the integrity of the surrounding skin and increase the risk for further impaired skin integrity and infection.
- Moisture/Secretions: Excessive moisture from perspiration, incontinence, wound drainage, or other bodily secretions can lead to skin maceration, irritation, and breakdown.
- Shearing/Friction/Pressure: Mechanical forces like shearing (skin layers sliding over each other), friction (rubbing against surfaces), and pressure (compression of tissues) can damage the skin, especially over bony prominences.
Signs and Symptoms of Impaired Skin Integrity
Recognizing the signs and symptoms of risk for impaired skin integrity is crucial for early intervention and prevention of further complications. These manifestations can be subjective (reported by the patient) or objective (observed by the nurse):
Subjective Symptoms (Patient Reports):
- Pain: Discomfort or tenderness in the affected area is a common complaint, especially with wounds or skin breakdown.
- Itching (Pruritus): Irritation or inflammation of the skin can cause itching.
- Numbness: Nerve damage or impaired circulation can lead to a loss of sensation or numbness in the affected and surrounding skin.
Objective Signs (Nurse Assesses):
- Changes to Skin Color:
- Erythema: Redness of the skin, indicating inflammation or increased blood flow.
- Bruising (Ecchymosis): Discoloration of the skin due to blood leakage into subcutaneous tissues.
- Blanching: Paleness or whitening of the skin when pressure is applied, which can indicate impaired circulation. Non-blanchable erythema is a key sign of pressure injury.
- Warmth to Skin: Increased temperature of the skin may indicate inflammation or infection.
- Swelling (Edema): Fluid accumulation in the tissues, often associated with inflammation or circulatory issues.
- Observed Open Areas or Breakdown: Visible disruptions in the skin surface, including abrasions, lacerations, fissures, blisters, or ulcers.
- Excoriation: Superficial skin damage caused by scratching or rubbing.
- Maceration: Softening and breakdown of the skin due to prolonged exposure to moisture, often appearing white or pale and wrinkled.
- Induration: Hardening of the skin, which can be a sign of underlying tissue damage or inflammation.
Expected Outcomes for Risk for Impaired Skin Integrity
The primary goals of nursing care for patients at risk for impaired skin integrity are to prevent skin breakdown, promote timely wound healing, and educate patients on preventive measures. Expected outcomes include:
- Patient will maintain intact skin integrity throughout their care.
- Patient will experience timely healing of any existing wounds without complications such as infection.
- Patient will demonstrate effective wound care practices, if applicable.
- Patient will verbalize understanding of pressure injury prevention strategies and skin care measures.
- Patient will actively participate in their skin care regimen.
Nursing Assessment for Risk for Impaired Skin Integrity
A comprehensive nursing assessment is the foundation of effective care planning for risk for impaired skin integrity. This involves gathering both subjective and objective data to identify risk factors, current skin condition, and patient-specific needs.
1. Conduct a Thorough Skin Assessment: A systematic head-to-toe skin examination should be performed upon admission, during unit transfers, and at least once per shift, or more frequently as indicated by patient condition and facility policy. This routine assessment allows for early detection of skin changes and potential breakdown. Pay particular attention to high-risk areas prone to pressure, such as:
- Sacrum and Coccyx
- Heels and Ankles
- Elbows
- Hips
- Shoulders
- Back of Head and Ears
- Between Skin Folds
2. Utilize the Braden Scale for Pressure Ulcer Risk Assessment: The Braden Scale is an evidence-based tool widely used to assess a patient’s risk for developing pressure injuries (also known as pressure ulcers or bedsores). It evaluates six key risk factors:
- Sensory Perception: Ability to feel and respond to discomfort or 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 or repositioning the patient.
Each category is scored on a scale, and the total score ranges from 6 to 23. A lower score indicates a higher risk for pressure injury. Institutional policy dictates the frequency of Braden Scale assessments, but nurses should also utilize it whenever they suspect a patient is at increased risk of skin breakdown.
3. Assess Circulatory Status: Evaluate peripheral circulation, sensation, and skin turgor. Poor skin turgor (decreased elasticity), diminished sensation (potential nerve damage), and impaired circulation (indicated by pallor, coolness, or discoloration, especially in lower extremities, and weak or absent pulses) significantly increase the risk for 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, paralysis, or those requiring bedrest are at high risk for pressure injuries due to sustained pressure. Patients using physical restraints are also at increased risk due to restricted movement and potential for friction.
5. Determine Risk Related to Moisture: Evaluate factors contributing to skin moisture, such as:
- Perspiration (Sweating): Excessive sweating, especially in skin folds.
- Incontinence (Urinary and Fecal): Exposure to urine and stool, which are irritating to the skin.
- Wound Drainage: Exudate from wounds can macerate surrounding skin.
- Fistula or Ostomy Drainage: Leakage from these sites can also contribute to skin moisture and irritation.
Patients with incontinence or excessive perspiration require meticulous skin care to maintain dryness and prevent breakdown.
6. Evaluate Self-Care Ability: Assess the patient’s ability to manage personal hygiene, incontinence care, and repositioning. Patients who are unable to perform self-care or request assistance are at higher risk for skin breakdown and require proactive nursing interventions.
7. Describe Existing Wounds Thoroughly: If skin breakdown is present, accurate and detailed documentation of wound characteristics is essential for monitoring healing progress and treatment effectiveness. Wound assessment should include:
- Location and Stage (if pressure injury): Use a validated staging system for pressure injuries.
- Size (Length, Width, Depth): Measure in centimeters.
- Wound Bed Characteristics: Describe tissue type (e.g., granulation, slough, eschar).
- Periwound Skin: Assess color, temperature, moisture, and presence of induration or maceration.
- Drainage: Note type (serous, sanguineous, serosanguineous, purulent), color, odor, and amount.
- Tunneling or Undermining: Measure depth and direction.
- Pain: Assess pain level using a pain scale.
Photography of the wound can be valuable for comparative purposes and tracking progress over time, with patient consent and according to facility policy.
8. Assess Nutritional and Hydration Status: Monitor the patient’s dietary intake, fluid balance, and nutritional laboratory values (e.g., serum albumin, prealbumin). Adequate hydration and nutrition, particularly protein intake, are crucial for wound healing and maintaining skin integrity.
9. Assess Stoma and Ostomy Sites: For patients with ostomies, assess the stoma site for:
- Color and Appearance: Stoma should be pink to red and moist.
- Protrusion: Stoma should protrude slightly from the skin.
- Peristomal Skin: Assess for irritation, breakdown, or infection.
- Appropriateness of Ostomy Appliance: Ensure proper fit and function of the pouching system.
Consultation with a wound ostomy continence nurse (WOCN) is recommended for complex stoma care.
Nursing Interventions for Risk for Impaired Skin Integrity
Nursing interventions are crucial for both preventing and managing risk for impaired skin integrity. These interventions are aimed at minimizing risk factors, protecting the skin, promoting healing, and educating patients and caregivers.
1. Implement Prescribed Wound Care Protocols: Follow established protocols and physician orders for specific wound types, sizes, and locations. Wound care protocols should be evidence-based and may include:
- Wound Cleansing: Using appropriate solutions (e.g., normal saline) and techniques.
- Debridement: Removal of necrotic tissue to promote healing (surgical, enzymatic, autolytic, mechanical, biologic).
- Dressing Selection: Choosing dressings that maintain a moist wound environment, protect the wound, and manage drainage (e.g., hydrocolloids, hydrogels, foams, alginates).
- Topical Medications: Applying prescribed ointments or creams (e.g., antimicrobial agents, barrier creams).
Consultation with a WOCN is recommended for complex or non-healing wounds.
2. Position and Reposition Patient Frequently: Reposition immobile patients at least every two hours, or more frequently based on individual needs and risk assessment, to relieve pressure on bony prominences. Utilize a turning schedule or turn clock as a reminder.
3. Ensure Adequate Skin Perfusion: Support bony prominences with pressure-redistributing devices to minimize pressure and promote blood flow. These devices may include:
- Pillows and Cushions: To offload heels, elbows, knees, and hips.
- Specialty Mattresses: Low-air loss mattresses, alternating pressure mattresses, and gel overlays to redistribute pressure.
- Heel and Elbow Protectors: Waffle boots, foam protectors, or gel pads.
4. Maintain Skin Hygiene and Manage Moisture: Keep the skin clean and dry.
- Gentle Cleansing: Use mild, pH-balanced cleansers and warm water. Avoid harsh soaps or hot water, which can dry out the skin.
- Pat Skin Dry: Avoid rubbing, which can cause friction.
- Apply Moisture Barrier: Use barrier creams or ointments to protect skin from excessive moisture, especially in incontinent patients.
- Manage Incontinence: Implement a bladder and bowel management program, using absorbent products and frequent skin checks and cleansing.
- Control Perspiration: Ensure a cool environment and use moisture-wicking linens.
5. Alleviate Pressure and Friction:
- Pressure-Redistributing Support Surfaces: Utilize appropriate mattresses and cushions.
- Lifting Devices: Use draw sheets or mechanical lifts to reposition patients and minimize friction and shear forces.
- Elevate Heels: Offload heels completely using pillows or heel suspension devices.
- Avoid Positioning Directly on Bony Prominences: Use pillows to position patients at a 30-degree lateral incline to avoid direct pressure on the trochanter.
- Limit Head Elevation: Keep head of bed at or below 30 degrees when possible to reduce shear.
6. Promote Optimal Nutrition and Hydration: Collaborate with a registered dietitian to ensure patients receive adequate nutrition and hydration.
- Protein-Rich Diet: Encourage intake of protein-rich foods or supplements to support tissue repair and regeneration.
- Adequate Fluid Intake: Ensure sufficient fluid intake to maintain skin hydration and circulation, unless contraindicated by medical conditions.
- Vitamin and Mineral Supplementation: Consider supplementation with vitamins and minerals known to support wound healing, such as vitamin C and zinc, as prescribed.
7. Protect Skin from Further Injury:
- Protective Clothing and Footwear: Encourage patients to wear socks and well-fitting, non-slip shoes to protect feet, especially for patients with neuropathy or impaired sensation.
- Avoid Adhesive Tape Directly on Skin: Use skin protectants or silicone-based adhesives if tape is necessary.
- Minimize Friction and Shear: Use proper transfer techniques and avoid dragging patients during repositioning.
8. Coordinate with Wound/Ostomy Specialist: Consult with a WOCN for complex wound management, ostomy care, or when standard interventions are not effective. WOCNs can provide specialized expertise and recommendations for advanced wound care modalities and ostomy management.
9. Minimize Irritants:
- Barrier Creams and Pastes: Apply barrier creams or pastes to protect skin exposed to moisture or irritants, such as around stomas or in perineal area.
- Adhesive Removers: Use adhesive removers to gently remove dressings and ostomy appliances without causing skin trauma.
- Avoid Harsh Chemicals and Irritants: Use gentle skin cleansers and avoid products containing alcohol, fragrances, or dyes, especially for patients with sensitive skin or radiation-treated skin.
10. Manage Ostomy Pouch System Effectively: For patients with ostomies:
- Proper Pouch Application: Ensure correct sizing of the wafer and secure application of the pouch system to prevent leakage and peristomal skin irritation.
- Regular Pouch Emptying: Instruct patients to empty ostomy pouches when they are 1/3 to 1/2 full to prevent excessive weight and potential detachment, which can lead to skin irritation and leakage.
- Patient Education: Teach patients and caregivers about proper ostomy care, including pouch application, emptying techniques, skin care, and troubleshooting common issues.
Nursing Care Plans for Risk for Impaired Skin Integrity
Nursing care plans provide a structured approach to addressing risk for impaired skin integrity. Here are examples of care plans tailored to different underlying causes:
Care Plan #1: Impaired Skin Integrity related to Immobility
Diagnostic Statement:
Risk for impaired skin integrity related to immobility secondary to spinal cord injury, as evidenced by prolonged bedrest and inability to independently reposition.
Expected Outcomes:
- Patient will maintain intact skin integrity without evidence of pressure injury throughout hospitalization.
- Patient will demonstrate understanding of pressure ulcer prevention measures by discharge.
- Patient will actively participate in repositioning and skin care within their physical limitations.
Assessment:
- Assess skin regularly (at least every shift) and after repositioning, paying close attention to bony prominences (sacrum, coccyx, heels, hips, elbows). Rationale: Early detection of skin changes allows for timely intervention.
- Determine patient’s mobility level using Braden Scale and functional assessment. Rationale: Identifies specific risk factors and guides individualized interventions.
- Assess need for and effectiveness of current positioning devices (e.g., pillows, specialty mattress). Rationale: Ensures proper pressure redistribution and support.
Interventions:
- Implement a turning schedule, repositioning patient at least every 2 hours. Rationale: Relieves pressure and promotes circulation.
- Utilize pressure-redistributing mattress and support surfaces. Rationale: Minimizes pressure on bony prominences.
- Keep skin clean and dry, especially after episodes of incontinence or perspiration. Rationale: Prevents maceration and irritation.
- Educate patient and caregivers on pressure ulcer prevention techniques, including repositioning, skin inspection, and proper nutrition. Rationale: Promotes patient and caregiver involvement and long-term prevention.
- Consult with physical therapy and occupational therapy for mobility and positioning strategies. Rationale: Interdisciplinary approach optimizes patient care.
Care Plan #2: Impaired Skin Integrity related to Diabetic Neuropathy
Diagnostic Statement:
Risk for impaired skin integrity related to decreased skin sensation secondary to diabetic neuropathy, as evidenced by reported numbness in feet and poor glycemic control.
Expected Outcomes:
- Patient will maintain intact skin on lower extremities throughout care.
- Patient will verbalize understanding of daily foot inspection and foot care practices within 24 hours.
- Patient will demonstrate proper foot care techniques by discharge.
- Patient will maintain blood glucose within target range to promote skin perfusion.
Assessment:
- Assess feet and lower legs daily for signs of skin breakdown, infection, or injury. Rationale: Early detection is crucial due to reduced sensation.
- Evaluate patient’s sensation in lower extremities using monofilament testing. Rationale: Quantifies degree of sensory loss and risk.
- Monitor blood glucose levels and HbA1c. Rationale: Poor glycemic control impairs wound healing and increases infection risk.
- Assess patient’s footwear and foot care practices. Rationale: Identifies potential risk factors and areas for education.
Interventions:
- Educate patient on diabetic neuropathy, importance of daily foot inspection, and proper foot care. Rationale: Empowers patient to take proactive measures.
- Instruct patient to wear protective footwear at all times, even indoors. Rationale: Prevents injury due to reduced sensation.
- Advise patient to avoid extremes of temperature (hot or cold) to feet. Rationale: Prevents burns or frostbite due to reduced sensation.
- Emphasize the importance of maintaining blood glucose control to improve circulation and promote healing. Rationale: Addresses underlying cause of impaired skin integrity.
- Refer to podiatry for routine foot care and management of any existing foot problems. Rationale: Specialized care for diabetic foot complications.
Care Plan #3: Impaired Skin Integrity related to Surgical Incision and Stoma Creation
Diagnostic Statement:
Risk for impaired skin integrity related to surgical incision and stoma creation to the abdomen, as evidenced by recent abdominal surgery and presence of ostomy.
Expected Outcomes:
- Patient will maintain intact peristomal skin and incision site free from infection and breakdown.
- Patient will verbalize understanding of peristomal skin care and ostomy pouch management within 24 hours.
- Patient will demonstrate proper ostomy pouch application and emptying techniques by discharge.
- Stoma will remain moist, pink, and viable.
Assessment:
- Assess surgical incision and peristomal skin daily for redness, drainage, swelling, and signs of infection. Rationale: Early detection of complications is essential.
- Evaluate stoma color, size, and protrusion. Rationale: Monitors stoma viability and healing.
- Assess ostomy pouch system for proper fit and seal. Rationale: Prevents leakage and peristomal skin irritation.
- Determine patient’s understanding of ostomy care and peristomal skin care. Rationale: Identifies learning needs and guides education.
Interventions:
- Collaborate with WOCN for stoma site assessment and ostomy management. Rationale: Specialized expertise in ostomy care.
- Cleanse peristomal skin gently with warm water and pat dry with each pouch change. Rationale: Maintains skin hygiene without irritation.
- Apply barrier paste or wafer to peristomal skin before pouch application. Rationale: Protects skin from stomal output and adhesive.
- Ensure proper fit of ostomy pouch wafer to prevent leakage and skin irritation. Rationale: Prevents peristomal skin breakdown.
- Educate patient and caregivers on ostomy care, peristomal skin care, pouch emptying, and troubleshooting common problems. Rationale: Empowers patient and caregivers to manage ostomy effectively.
Care Plan #4: Impaired Skin Integrity related to Radiation Therapy
Diagnostic Statement:
Risk for impaired skin integrity related to radiation therapy to the chest area, as evidenced by planned radiation treatments and potential for radiation dermatitis.
Expected Outcomes:
- Patient will maintain skin integrity in radiation treatment area throughout therapy, minimizing radiation dermatitis.
- Patient will verbalize understanding of skin care measures during radiation therapy within 24 hours.
- Patient will report any signs of skin breakdown or irritation to healthcare team promptly.
Assessment:
- Assess skin in radiation treatment area before each treatment for baseline and ongoing monitoring. Rationale: Detects early signs of radiation dermatitis.
- Evaluate patient’s understanding of expected skin reactions to radiation and recommended skin care. Rationale: Identifies education needs and ensures patient preparedness.
- Document any skin changes (erythema, dryness, peeling, blistering) using a standardized grading scale for radiation dermatitis. Rationale: Tracks severity and guides management.
Interventions:
- Educate patient on gentle skin care during radiation therapy:
- Cleanse skin gently with mild soap and water, pat dry. Rationale: Avoids irritation from harsh cleansers.
- Avoid scrubbing or rubbing skin. Rationale: Minimizes friction and irritation.
- Apply prescribed moisturizer (fragrance-free, lanolin-free) after each treatment. Rationale: Keeps skin hydrated and reduces dryness.
- Wear loose, soft clothing. Rationale: Minimizes friction and allows skin to breathe.
- Avoid sun exposure to treated area. Rationale: Prevents further skin damage.
- Instruct patient to avoid using lotions, creams, or powders immediately before radiation treatment. Rationale: Some products can interfere with radiation delivery.
- Monitor skin regularly for signs of radiation dermatitis and report changes to radiation oncology team. Rationale: Allows for timely intervention and management of skin reactions.
- Collaborate with radiation oncology team for management of radiation dermatitis, which may include topical corticosteroids or wound dressings. Rationale: Interdisciplinary approach to manage radiation-induced skin reactions.
References
- Black, J. M., & Hawks, J. H. (2021). Medical-surgical nursing: Pathophysiological concepts. Elsevier.
- Doughty, D. B., McNichol, L., & Droegemueller, L. (2018). WOCN core curriculum: Wound, ostomy and continence nursing. Wolters Kluwer.
- National Pressure Ulcer Advisory Panel (NPUAP). (2019). Prevention and treatment of pressure ulcers: Clinical practice guideline. Author.
- Registered Nurses’ Association of Ontario (RNAO). (2016). Risk assessment and prevention of pressure ulcers. Author.
- Woo, K. Y., Beeckman, D., & Chakravarthy, D. (2017). Management of moisture-associated skin damage: State of the art. Advances in Wound Care, 6(2), 49-56.
This comprehensive guide provides nurses with essential knowledge and strategies for addressing risk for impaired skin integrity. By understanding the causes, recognizing the signs and symptoms, conducting thorough assessments, implementing evidence-based interventions, and developing individualized care plans, nurses can significantly reduce the incidence of skin breakdown and promote optimal patient outcomes. Continuous education and collaboration with interdisciplinary teams are crucial for staying abreast of best practices in skin integrity management.
