Bruising Nursing Diagnosis: Comprehensive Guide to Assessment and Care

The skin, our body’s largest organ, serves as the primary defense against external pathogens. Its integrity is crucial in preventing infections and maintaining overall health. When this protective barrier is compromised due to various factors, including injury or underlying medical conditions, it can manifest in numerous ways, one of which is bruising. As healthcare professionals, particularly nurses, a thorough understanding of skin integrity and the significance of bruising is paramount for accurate diagnosis, effective intervention, and patient education.

This article delves into the critical aspects of “Bruising Nursing Diagnosis” within the broader context of impaired skin integrity. We will explore the causes, signs and symptoms, assessment techniques, and nursing interventions related to bruising, aiming to equip nurses with the knowledge and skills to provide optimal patient care.

Causes of Impaired Skin Integrity and Bruising

Impaired skin integrity, leading to conditions such as bruising, can arise from a multitude of internal and external factors. Understanding these causes is the first step in effective nursing diagnosis and care planning.

Internal Factors Contributing to Bruising and Skin Impairment:

Extremes in Age: Both very young and elderly individuals have more fragile skin that is susceptible to bruising and injury. Infants have thinner skin, while older adults experience age-related skin changes like decreased collagen and elasticity, making them more prone to bruising even from minor trauma.
Cognitive Impairment: Patients with cognitive deficits may be unable to communicate discomfort or reposition themselves, increasing their risk of pressure injuries and related bruising. They might also be prone to falls and injuries leading to bruises.
Physical Immobilization/Bedrest & Paralysis: Prolonged pressure on bony prominences due to immobility or paralysis restricts blood flow, leading to tissue damage and potential bruising.
Surgery: Surgical incisions disrupt skin integrity directly. Post-operative bruising around incision sites is common but needs to be monitored for signs of complications.
Wounds: Existing wounds compromise the skin’s protective barrier, making the surrounding tissue more vulnerable and potentially leading to bruising as part of the healing process or due to secondary injury.
Underlying Medical Conditions: Certain diseases, such as bleeding disorders, thrombocytopenia (low platelet count), liver disease, and Cushing’s syndrome, can increase the propensity to bruise easily.
Nutritional Deficiencies: Lack of essential nutrients like Vitamin C and Vitamin K can impair collagen synthesis and blood clotting, respectively, both contributing to increased bruising.

External Factors Contributing to Bruising and Skin Impairment:

Hyperthermia: Elevated body temperature can lead to increased perspiration, causing skin maceration and increased vulnerability to damage, potentially resulting in bruising if coupled with pressure or friction.
Hypothermia: Conversely, low body temperature can reduce blood flow and tissue oxygenation, making the skin more susceptible to injury and bruising.
Radiation: Radiation therapy can cause skin reactions, including erythema (redness) and breakdown, making the skin more fragile and easily bruised.
Chemicals: Exposure to harsh chemicals can irritate and damage the skin, weakening its integrity and increasing susceptibility to bruising.
Moisture/Secretions: Prolonged exposure to moisture from sweat, urine, or wound drainage can lead to skin maceration and breakdown, predisposing the skin to bruising and further injury.
Shearing/Friction/Pressure: These mechanical forces, particularly common in bedridden patients, can damage skin and underlying tissues, resulting in pressure injuries and associated bruising.

Signs and Symptoms of Impaired Skin Integrity and Bruising

Recognizing the signs and symptoms of impaired skin integrity, particularly those related to bruising, is crucial for timely intervention. Nurses must be vigilant in assessing patients for both subjective reports and objective findings.

Subjective Symptoms (Patient Reports):

Pain: Bruising can be painful, especially when touched or moved. Patients may report localized pain at the site of the bruise.
Itching: While not directly related to bruising itself, itching can be a symptom of underlying skin irritation or conditions that might also contribute to skin fragility and bruising.
Numbness to Affected and Surrounding Skin: Numbness can indicate nerve damage, which may be associated with injuries that also cause bruising.

Objective Signs (Nurse Assesses):

Changes to Skin Color (Erythema, Bruising, Blanching): This is a key objective sign. Bruising, or ecchymosis, presents as discoloration of the skin due to blood leaking from damaged blood vessels into surrounding tissues. Initially, bruises may appear reddish or bluish, progressing through shades of purple, black, green, and yellow as they heal. Erythema (redness) may indicate inflammation or infection around a bruise or wound. Blanching (skin turning pale when pressed) can be an early sign of pressure damage, although bruising itself does not blanch.
Warmth to Skin: Warmth around a bruise can be a sign of inflammation or infection.
Swelling to Tissues: Swelling (edema) is a common response to tissue injury and can accompany bruising.
Observed Open Areas or Breakdown, Excoriation: While bruising is typically subcutaneous, its presence might be associated with other forms of skin breakdown, such as abrasions, lacerations, or pressure ulcers. Excoriation (scratching or abrasion of the skin) can also be a sign of skin irritation that might predispose to bruising.

Nursing Assessment for Bruising and Impaired Skin Integrity

A comprehensive nursing assessment is vital for identifying and managing impaired skin integrity and bruising. This involves systematic observation, palpation, and the use of assessment tools.

1. Conduct a Thorough Skin Assessment: A head-to-toe skin examination should be performed upon admission, during unit transfers, and regularly (e.g., once per shift, as per facility policy). This systematic approach ensures that all areas, including those prone to breakdown and bruising, are assessed. Pay particular attention to bony prominences (heels, coccyx, elbows, hips) and areas under medical devices.

2. Utilize Braden Skin Assessment Scale: The Braden Scale is an evidence-based tool for assessing pressure injury risk. While not directly assessing bruising, it evaluates factors that contribute to skin breakdown, which can be associated with bruising. The six criteria are:

Sensory Perception: Ability to sense and respond to discomfort related to pressure.
Moisture: Degree to which skin is exposed to moisture.
Activity: Level of physical activity.
Mobility: Ability to change and control body position.
Nutrition: Usual food intake pattern.
Friction and Shear: Forces of friction and shear acting on the skin.

A lower Braden Scale score indicates a higher risk of pressure injury development. While bruising is not directly scored, patients at high risk on the Braden scale require close monitoring for all forms of skin compromise, including bruising.

3. Assess Circulatory Status: Evaluate skin circulation, sensation, and turgor. Poor skin turgor (decreased elasticity), diminished sensation (neuropathy), and impaired circulation (indicated by cool skin, pallor, or cyanosis) increase the risk of tissue injury, including bruising. Palpate peripheral pulses and assess capillary refill. Note any skin discoloration, particularly in the lower legs, which could indicate venous insufficiency.

4. Assess Activity Level and Mobility: Observe the patient’s ability to move in bed and ambulate. Immobility is a major risk factor for pressure injuries and bruising. Patients with limited mobility require frequent repositioning and pressure relief measures.

5. Determine Risk of Skin Breakdown Related to Moisture: Assess for incontinence (urinary or fecal), excessive perspiration, and wound drainage. Moisture macerates the skin, making it more fragile and susceptible to bruising and breakdown.

6. Evaluate Patient’s Ability for Self-Care: Determine the patient’s capacity to manage personal hygiene, including skin care and incontinence management. Patients with self-care deficits require assistance to maintain skin integrity and prevent bruising.

7. Describe Bruising and Wounds Accurately: If bruising or wounds are present, document their location, size (length, width, diameter), color, and surrounding skin condition. For bruises, note the stage of discoloration (reddish, bluish, purple, black, green, yellow) as this can help estimate the age of the bruise. Document any associated findings like swelling, warmth, pain, or drainage. Consider photographic documentation for comparative purposes and to track healing.

8. Assess Nutrition and Hydration Status: Evaluate the patient’s nutritional intake and hydration status. Malnutrition and dehydration impair tissue repair and increase skin fragility, making bruising more likely and hindering healing. Assess for signs of dehydration (dry mucous membranes, poor skin turgor) and malnutrition.

9. Consider Medication History: Certain medications, such as anticoagulants (warfarin, heparin), antiplatelet drugs (aspirin, clopidogrel), and corticosteroids, increase the risk of bruising. Review the patient’s medication list for these medications.

Nursing Interventions for Bruising and Impaired Skin Integrity

Nursing interventions are crucial for both preventing and treating impaired skin integrity and managing bruising.

1. Implement Pressure Injury Prevention Protocols: For patients at risk for pressure injuries (identified through Braden Scale or clinical assessment), implement preventive measures:

Reposition Patient Frequently: Turn and reposition immobile patients at least every two hours, or more frequently as needed, following a turning schedule.
Pressure Relief Devices: Use pressure-redistributing mattresses (low-air loss mattresses), cushions, and overlays on beds and chairs.
Protect Bony Prominences: Use pillows, foam wedges, or specialized devices to offload pressure from bony prominences like elbows, knees, hips, and heels.

2. Ensure Adequate Skin Perfusion: Promote optimal circulation to prevent tissue ischemia and bruising:

Avoid Prolonged Pressure: Minimize pressure on vulnerable areas through frequent repositioning and pressure relief devices.
Maintain Hydration: Adequate hydration supports blood volume and tissue perfusion.
Promote Activity: Encourage mobility and activity as tolerated to improve circulation.

3. Maintain Skin Hygiene and Manage Moisture: Keep skin clean and dry to prevent maceration and irritation:

Gentle Cleansing: Cleanse skin with mild, pH-balanced cleansers and warm water. Avoid harsh soaps and hot water.
Dry Skin Thoroughly: Pat skin dry after cleansing, paying attention to skin folds and areas prone to moisture accumulation.
Manage Incontinence: Implement a bowel and bladder management program to minimize skin exposure to urine and stool. Use absorbent incontinence products and frequent skin checks and cleansing.
Control Perspiration: Keep the environment cool and dry to reduce perspiration. Use moisture-wicking fabrics for clothing and bedding.

4. Implement Wound Care Protocols as Prescribed: For existing wounds or skin breakdown, follow prescribed wound care protocols. This may include:

Wound Cleansing: Cleanse wounds as ordered, using appropriate solutions (e.g., saline).
Dressing Application: Apply appropriate dressings to protect the wound, promote healing, and manage exudate. Choose dressings based on wound type, depth, and drainage.
Monitor Wound Healing: Regularly assess wounds for signs of healing or complications (infection, delayed healing). Document wound progress.

5. Alleviate Pressure and Friction: Minimize mechanical forces that contribute to skin damage and bruising:

Lift, Don’t Drag: When repositioning patients, lift rather than drag them to reduce friction and shear forces.
Use Transfer Aids: Utilize draw sheets, transfer boards, or mechanical lifts to minimize friction during transfers.
Smooth Linens: Ensure bed linens are smooth and wrinkle-free to reduce friction.

6. Promote Proper Nutrition and Hydration: Support tissue repair and skin health through adequate nutrition and hydration:

Balanced Diet: Encourage a diet rich in protein, vitamins (especially Vitamin C and K), and minerals essential for skin health and wound healing.
Fluid Intake: Ensure adequate fluid intake to maintain hydration and tissue perfusion.
Nutritional Supplements: Consider nutritional supplements if dietary intake is insufficient or if deficiencies are identified.

7. Protect Skin from Further Injury: Prevent further trauma to compromised skin:

Skin Protection: Use protective sleeves, heel protectors, or other devices to shield fragile skin from friction and pressure.
Safe Environment: Ensure a safe environment to prevent falls and injuries that could lead to bruising.
Gentle Handling: Handle patients with care to avoid accidental bumps or pressure.

8. Educate Patient and Family: Provide education to patients and families on skin care, pressure injury prevention, and bruise management:

Skin Care Techniques: Teach proper skin cleansing, moisturizing, and protection techniques.
Repositioning Techniques: Educate on the importance of repositioning and demonstrate proper techniques.
Risk Factors: Explain risk factors for skin breakdown and bruising.
Early Signs of Problems: Instruct patients and families to report any new bruises, skin redness, breaks, or changes in skin condition.

9. Coordinate with Wound/Ostomy Specialist: Consult with a wound care specialist or ostomy nurse for complex wounds, non-healing wounds, or ostomy-related skin issues. Specialists can provide expert recommendations for wound care protocols and product selection.

10. Avoid Irritants: Minimize exposure to potential skin irritants:

Mild Products: Use fragrance-free, hypoallergenic skin care products.
Avoid Harsh Chemicals: Protect skin from harsh chemicals and cleaning agents.
Barrier Creams: Use barrier creams to protect skin exposed to moisture or irritants.

Nursing Care Plans for Impaired Skin Integrity and Bruising

Nursing care plans provide a structured approach to patient care, outlining diagnoses, expected outcomes, assessments, and interventions. Here are examples of nursing care plan components relevant to “bruising nursing diagnosis” and impaired skin integrity.

Care Plan Example: Risk for Impaired Skin Integrity related to Immobility

Diagnostic Statement: Risk for Impaired Skin Integrity related to immobility secondary to stroke.

Expected Outcomes:

Patient will maintain intact skin integrity throughout hospitalization.
Patient will demonstrate understanding of pressure injury prevention measures by discharge.
Patient will experience no new bruising or skin breakdown during hospitalization.

Assessment:

Assess skin integrity daily and with each repositioning: Monitor for redness, blanching, bruising, or skin breakdown, particularly over bony prominences.
Assess Braden Scale score on admission and regularly: Identify risk level for pressure injury development.
Assess mobility limitations: Determine patient’s ability to reposition self and level of assistance required.
Assess nutritional and hydration status: Identify any deficits that could impair skin integrity.

Interventions:

Implement pressure injury prevention protocol:
- Reposition patient every 2 hours using a turning schedule.
- Utilize a pressure-redistributing mattress.
- Use pillows to offload bony prominences (heels, elbows, hips).
Maintain skin hygiene:
- Cleanse skin daily with mild cleanser and pat dry.
- Apply moisturizer to dry skin areas, avoiding bony prominences if moisture is a concern.
- Manage incontinence promptly to prevent skin maceration.
Promote adequate nutrition and hydration:
- Encourage adequate oral intake of fluids and a balanced diet.
- Consult dietitian if nutritional deficits are suspected.
Educate patient and family on pressure injury prevention:
- Teach repositioning techniques.
- Explain risk factors and preventive measures.
- Provide written materials on skin care and pressure injury prevention.

Care Plan Example: Impaired Skin Integrity related to Bruising Secondary to Trauma

Diagnostic Statement: Impaired Skin Integrity related to bruising secondary to fall, as evidenced by ecchymosis on left hip and reports of pain.