The skin, our body’s largest organ, acts as a vital protective barrier against external threats, preventing pathogens from causing infections and illness. When this barrier is compromised due to burns, cuts, abrasions, ulcers, incisions, or wounds, it creates an entry point for bacteria and other harmful microorganisms, significantly increasing the risk of infection. For healthcare professionals, especially nurses, a thorough understanding of assessing, preventing, treating, and educating patients about impaired skin integrity is paramount. This knowledge is critical in various scenarios, including burn injuries, where “Burn Nursing Diagnosis” plays a crucial role in patient care.
This article delves into the multifaceted aspects of impaired skin integrity, providing an in-depth look at its causes, signs and symptoms, nursing assessments, interventions, and tailored care plans, with a specific focus on the nursing diagnosis related to burns.
Common Causes of Impaired Skin Integrity
Impaired skin integrity can stem from a wide array of factors, broadly categorized as internal and external:
Internal Factors:
- Extremes in Age: Both very young and elderly individuals have more delicate and vulnerable skin.
- Cognitive Impairment: Patients with cognitive deficits may be unable to communicate discomfort or reposition themselves, leading to prolonged pressure.
- Physical Immobilization/Bedrest: Limited mobility increases pressure on specific skin areas, reducing blood flow and causing breakdown.
- Paralysis: Loss of motor function prevents natural repositioning, leading to sustained pressure and potential skin damage.
External Factors:
- Hyperthermia: Elevated body temperature can lead to increased perspiration and skin maceration.
- Hypothermia: Low body temperature can reduce circulation and tissue oxygenation, making skin more susceptible to injury.
- Radiation: Radiation therapy can cause skin irritation, burns, and breakdown.
- Chemicals: Exposure to harsh chemicals can irritate and damage the skin.
- Moisture/Secretions: Excessive moisture from sweat, urine, stool, or wound drainage can soften the skin and increase friction.
- Shearing/Friction/Pressure: Mechanical forces, such as dragging a patient across bed linens or prolonged pressure on bony prominences, can damage skin layers.
- Surgery: Surgical incisions disrupt skin integrity, creating a potential entry point for infection.
- Wounds: Pre-existing wounds, regardless of origin, represent areas of impaired skin integrity.
Recognizing Signs and Symptoms of Impaired Skin Integrity
Identifying impaired skin integrity involves recognizing both subjective reports from the patient and objective observations during a physical assessment.
Subjective Symptoms (Patient Reports):
- Pain: Discomfort or tenderness in the affected area.
- Itching: Pruritus, which can indicate skin irritation or breakdown.
- Numbness: Loss of sensation in or around the affected skin, potentially signaling nerve damage or impaired circulation.
Objective Signs (Nurse Assesses):
- Changes to Skin Color:
- Erythema: Redness, indicating inflammation or pressure.
- Bruising: Ecchymosis, suggesting trauma or pressure damage to blood vessels.
- Blanching: Pale skin that doesn’t return to its normal color after pressure is released, indicating impaired circulation.
- Warmth to Skin: Increased temperature in the affected area, possibly due to inflammation or infection.
- Swelling to Tissues: Edema, indicating fluid accumulation and potential tissue damage.
- Observed Open Areas or Breakdown: Visible breaks in the skin surface, ranging from superficial abrasions to deep ulcers.
- Excoriation: Skin breakdown caused by scratching or rubbing.
Expected Outcomes for Nursing Care
Nursing care for impaired skin integrity aims to achieve several key outcomes:
- Maintain Intact Skin Integrity: Prevent further skin breakdown in at-risk areas.
- Promote Timely Wound Healing: Facilitate the healing of existing wounds without complications.
- Demonstrate Effective Wound Care: Patient and/or caregiver will correctly perform wound care procedures.
- Verbalize Proper Prevention of Pressure Injuries: Patient and/or caregiver will understand and articulate strategies to prevent pressure ulcers and other skin injuries.
Comprehensive Nursing Assessment for Impaired Skin Integrity
A thorough nursing assessment is the cornerstone of effective care for patients with or at risk of impaired skin integrity.
1. Conduct a Systematic Skin Assessment:
Perform a comprehensive head-to-toe skin examination upon admission, during unit transfers, and at least once per shift. This routine assessment is crucial for early detection and prevention of skin breakdown. Pay particular attention to high-risk areas such as heels, sacrum, elbows, and hips, which are prone to pressure injuries.
2. Utilize the Braden Scale for Pressure Injury Risk Assessment:
The Braden Scale is an evidence-based tool used to assess a patient’s risk of developing pressure injuries. It evaluates six key criteria:
- Sensory Perception: Ability to feel and respond to discomfort.
- Moisture: Degree of skin wetness.
- 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 being moved.
Scores range from 6 to 23, with lower scores indicating a higher risk of pressure injury. Institutional policies dictate the frequency of Braden Scale assessments, but nurses should also utilize it whenever they suspect a risk of skin breakdown.
3. Evaluate Circulatory Status:
Assess skin circulation, sensation, and turgor. Poor skin turgor (decreased elasticity), diminished sensation (potential nerve damage), and compromised circulation (indicated by skin discoloration and weak pulses) significantly 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. Immobility is a major risk factor for skin breakdown. Patients using restraints are also at increased risk due to restricted movement.
5. Determine Moisture-Related Skin Breakdown Risk:
Evaluate factors contributing to excessive skin moisture, such as:
- Perspiration (Sweat)
- Urinary Incontinence
- Fecal Incontinence
- Wound Drainage
Incontinence significantly elevates the risk of skin breakdown due to prolonged exposure to moisture and irritants.
6. Evaluate Self-Care Ability:
Assess the patient’s capacity to manage personal hygiene and incontinence independently. Patients who are incontinent or unable to seek assistance for toileting require vigilant monitoring to maintain skin dryness and cleanliness.
7. Wound Description and Documentation:
Accurate and detailed documentation of existing wounds and skin breakdown is essential for tracking healing progress and treatment effectiveness. Wound assessments should include:
- Location and Stage (if applicable)
- Size (length, width, depth)
- Wound Bed Characteristics (color, tissue type)
- Periwound Skin Condition
- Drainage (type, color, amount, odor)
- Presence of Tunneling or Undermining
Taking photographs of wounds can be beneficial for comparative assessments over time.
8. Assess Nutritional and Hydration Status:
Monitor the patient’s dietary intake and fluid balance. Adequate hydration and nutrition are crucial for delivering oxygen and nutrients to wound sites, promoting healing. Protein is particularly vital for tissue repair and regeneration.
9. Stoma and Ostomy Assessment:
For patients with ostomies, assess the stoma site for proper healing, color, and size. Evaluate the appropriateness and fit of the ostomy appliance. Wound care specialists are often involved in stoma assessments.
Nursing Interventions to Promote Skin Integrity
Effective nursing interventions are crucial for preventing and treating impaired skin integrity.
1. Implement Prescribed Wound Care Protocols:
Apply wound care protocols tailored to the specific type, size, and location of the wound. These protocols are typically guided by wound care specialists or institutional policies and procedures.
2. Optimize Patient Positioning and Pressure Relief:
Position patients comfortably, protecting bony prominences from prolonged pressure. Reposition immobile patients at least every two hours, or more frequently as per facility protocols, utilizing turn clocks as reminders.
3. Ensure Adequate Skin Perfusion:
Utilize pressure-redistributing support surfaces such as:
- Cushions and Pillows
- Specialty Mattresses (low-air loss, air-fluidized)
- Heel and Elbow Protectors
These devices help offload pressure from bony prominences like elbows, knees, hips, and heels, promoting blood flow.
4. Manage Moisture and Maintain Skin Dryness:
Prioritize keeping the patient’s skin clean and dry. Promptly address incontinence, perspiration, and wound drainage. Use absorbent pads and moisture-wicking dressings as needed. Regularly change bed linens and clothing to prevent prolonged skin exposure to moisture.
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 to redistribute pressure and minimize friction and shear forces.
6. Promote Optimal Nutrition and Hydration:
Encourage a balanced diet rich in protein, vitamins, and minerals to support tissue repair. Ensure adequate fluid intake to maintain hydration and promote circulation. Collaborate with dietitians to develop individualized nutrition plans.
7. Protect Skin from Further Injury:
Implement measures to protect fragile skin from trauma. This includes:
- Using socks and non-slip footwear.
- Padding splints and casts.
- Avoiding tape directly on fragile skin.
- Educating patients with compromised neurovascular status (e.g., diabetic neuropathy) on foot care and injury prevention.
8. Consult Wound and Ostomy Specialists:
Collaborate with wound and ostomy specialists for expert recommendations, evaluations, and guidance on complex wound care and ostomy management.
9. Minimize Skin Irritation:
Utilize barrier creams, pastes, or powders to protect skin from irritants like moisture and friction, particularly around stomas or areas prone to maceration. Adhesive removers can facilitate pouch changes for ostomy patients without causing skin trauma.
10. Ostomy Pouch Management:
Educate patients and caregivers on proper ostomy pouch application, emptying techniques, and skin care around the stoma. Correct pouch sizing and secure application are essential to prevent leakage and skin irritation. Empty ostomy pouches when they are one-third to one-half full to prevent excessive weight and potential detachment.
Nursing Care Plans for Impaired Skin Integrity
Nursing care plans provide structured frameworks for addressing impaired skin integrity, outlining diagnostic statements, expected outcomes, assessments, and interventions. Here are examples of care plans addressing various causes of impaired skin integrity, including a specific example relevant to “burn nursing diagnosis.”
Care Plan #1: Impaired Skin Integrity Related to Immobility
Diagnostic Statement: Impaired skin integrity related to immobility as evidenced by a Stage 2 pressure ulcer on the sacrum.
Expected Outcomes:
- Patient will demonstrate improvement of pressure ulcer from Stage 2 to Stage 1 within 2 weeks of nursing interventions.
- Patient will maintain dry and clean skin throughout each shift.
- Patient will verbalize understanding of and cooperation with wound care regimen within 24 hours.
- Patient will list three strategies to prevent pressure ulcers within 24 hours.
Assessments:
- Regular Skin and Wound Assessment: Assess skin integrity and pressure ulcer status at least once per shift, noting any changes in size, drainage, or periwound skin.
- Mobility Assessment: Determine the patient’s level of mobility and need for assistance with repositioning.
- Need for Positioning Devices: Evaluate the need for and proper use of pressure-redistributing devices.
Interventions:
- Wound Care as Prescribed: Implement prescribed wound care protocols for the sacral pressure ulcer.
- Repositioning and Pressure Relief: Reposition patient every two hours, using pillows and positioning devices to offload pressure from bony prominences.
- Maintain Skin Hygiene: Keep skin clean and dry, especially in the sacral area. Address incontinence promptly.
- Utilize Support Surfaces: Employ appropriate support surfaces such as a low-air loss mattress.
- Promote Nutrition and Hydration: Encourage adequate nutrition and hydration 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 on the left lower leg.
Expected Outcomes:
- Patient will exhibit intact skin on lower extremities by discharge.
- Patient will verbalize three methods to prevent skin infection within 24 hours.
- Patient will maintain adequate skin perfusion as evidenced by controlled blood glucose levels throughout each shift.
- Patient will demonstrate daily skin inspection of lower extremities within 24 hours.
Assessments:
- Assess for Skin Infection: Monitor the lower leg wound for signs of infection (redness, drainage, warmth, odor, swelling).
- Assess Skin Perfusion: Evaluate circulation and sensation in the lower extremities.
- Monitor Blood Glucose Levels: Regularly monitor and manage blood glucose levels.
Interventions:
- Blood Glucose Control: Administer medications and implement strategies to maintain blood glucose within target range.
- Patient Education on Diabetic Neuropathy and Skin Checks: Educate the patient about diabetic neuropathy, the importance of daily foot inspections, and protective foot care.
- Ensure Foot Protection: Advise the patient to wear protective footwear at all times to prevent foot injuries.
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 each shift assessment.
- Patient will list three ways to protect the stoma from skin breakdown within 24 hours.
- Patient will demonstrate proper ostomy pouch fitting and emptying techniques within 24 hours.
Assessments:
- Surgical Indication and Stoma Type: Understand the reason for surgery and the type of stoma created.
- Incision and Stoma Assessment: Assess the surgical incision and stoma for healing, color, and characteristics.
- Dietary Assessment: Evaluate the patient’s dietary intake and need for nutritional support.
Interventions:
- Wound/Ostomy Specialist Consultation: Collaborate with a wound/ostomy specialist for stoma care guidance.
- Meal Planning and Dietary Education: Educate the patient on dietary modifications to manage ostomy output.
- Minimize Skin Irritation Around Stoma: Utilize barrier pastes and powders to protect peristomal skin from irritation.
- Ostomy Pouch Education: Teach the patient proper pouch application, emptying, and skin care techniques.
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 dressings throughout each shift.
- Patient will verbalize cooperation and compliance with wound care regimen throughout each shift.
- Patient will list three strategies to prevent skin infection in burn wounds within 24 hours.
Assessments:
- Burn Wound Severity: Assess the extent and depth of the burn wound to determine infection risk and guide treatment.
- Degree of Burn: Classify the burn according to degree (first, second, third, or fourth) to determine the depth of tissue damage.
- Patient Knowledge of Wound Dressing: Assess the patient’s understanding and acceptance of burn wound dressing changes.
Interventions:
- Wound Dressing Application: Apply appropriate burn wound dressings using aseptic technique to prevent infection and promote healing.
- Regular Wound Cleansing and Debridement: Cleanse the burn wound regularly to remove debris and exudate. Perform or assist with wound debridement as indicated.
- Promote New Skin Growth: Implement strategies to promote tissue regeneration and wound closure, potentially including skin tissue engineering techniques.
- Encourage Patient Compliance with Wound Care: Provide adequate pain management before dressing changes and educate the patient on the importance of compliance for healing and infection prevention.
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 radiation-related skin irritation within 24 hours.
- Patient will promptly report worsening skin breakdown (peeling, open areas, drainage) to the nurse.
Assessments:
- Pre-treatment Skin Assessment: Assess skin integrity before each radiation treatment to monitor for changes.
- Patient Understanding of Skin Reactions: Assess the patient’s understanding of expected and abnormal skin reactions to radiation therapy.
Interventions:
- Moisturize After Treatments: Instruct the patient to apply fragrance-free, lanolin-free moisturizer to the treated area after each radiation session.
- Maintain Skin Hygiene: Advise the patient to keep the treated skin clean and dry, using mild soap and warm water.
- Avoid Abrasive Skin Products: Instruct the patient to avoid harsh soaps, antibacterial cleansers, and alcohol-based products.
- Loose Clothing and Comfortable Bra: Recommend wearing loose, cotton clothing and a comfortable, non-underwire bra (if applicable).
- Avoid Sun Exposure: Advise the patient to protect the treated area from direct sun exposure with loose clothing or non-irritating sunscreen.
References
(References would be listed here if explicitly provided in the original article. In this case, the original article does not list specific references, but the website “nursetogether.com” likely draws upon established nursing and medical knowledge.)
