Tissue integrity is paramount to overall health, acting as the body’s primary defense against external threats. This system, comprising the skin, cornea, subcutaneous tissues, and mucous membranes, typically provides robust protection. However, various factors can compromise this barrier, leading to impaired tissue integrity and potentially severe complications, including necrotizing fasciitis. Understanding the nursing diagnosis related to impaired skin integrity and its severe manifestations is crucial for effective patient care.
Understanding Tissue Integrity
The integumentary system is the body’s shield. When intact, it effectively wards off external threats. Physical trauma, such as injuries from accidents or surgery, is a common cause of tissue integrity impairment. Thermal injuries like burns and frostbite, chemical injuries from drug reactions, infections, nutritional and fluid imbalances, and circulatory issues like pressure injuries also contribute.
While the body often repairs minor tissue damage, untreated or severe cases can lead to complications. Failure to heal can result in connective tissue replacement of damaged tissue, local or systemic infections, and ultimately, necrosis. Factors like age, weight loss, poor nutrition and hydration, excessive moisture or dryness, smoking, and compromised blood flow further increase the risk. Personal hygiene habits, occupational hazards, and environmental exposures also play a significant role (Kottner et al., 2020).
Signs of impaired skin integrity range from sensory discomfort and inflammation to visible lesions and wounds. These can significantly diminish quality of life, causing itching, pain, disfigurement, and disability, and increasing risks of allergies and secondary infections. The global impact of skin diseases is growing, especially with aging populations (Kottner et al., 2020).
Wound Care Fundamentals
A wound is defined as a disruption in the normal structure and function of skin and soft tissues. Acute wounds follow typical healing processes, while chronic wounds are physiologically impaired (Armstrong & Meyr, 2023). Wound healing is intricate, influenced by internal and external factors that can either aid or hinder recovery. Nurses, collaborating with healthcare teams, are essential in managing these factors to foster optimal healing conditions (Ernstmeyer & Christman, 2021).
Phases of Wound Healing
Wound healing progresses through four distinct phases: hemostasis, inflammation, proliferation, and maturation.
Types of Wound Healing
There are three classifications of wound healing:
- Primary Intention: Wounds closed by sutures, staples, or adhesives, healing beneath the closure. This is typical for surgical incisions and clean lacerations with approximated edges.
- Secondary Intention: Wounds left open to heal from the bottom up through granulation tissue formation. Examples include pressure injuries and injuries with tissue loss. These wounds carry a higher infection risk.
- Tertiary Intention: Wounds initially left open due to infection or other complications and closed at a later stage once the infection resolves. These wounds experience delayed healing and increased scarring (Ernstmeyer & Christman, 2021).
Common Causes of Impaired Skin Integrity
The etiology of impaired skin integrity includes:
- Physical Trauma: Accidents, injuries, cuts, and blunt trauma disrupting skin structure.
- Thermal Factors: Extreme temperatures causing burns or frostbite.
- Chemical Injury: Adverse drug reactions or chemical contact damaging skin.
- Infection: Pathogen invasion and damage to skin tissue.
- Nutritional Imbalances: Deficiencies affecting skin health and repair.
- Fluid Imbalances: Dehydration or fluid overload compromising skin integrity.
- Altered Circulation: Conditions like pressure injuries reducing blood flow.
- Age: Thinner, less elastic skin in older adults increases vulnerability.
- Weight Loss: Reduced cushioning and support for skin.
- Poor Nutrition and Hydration: Inadequate nutrient and fluid intake.
- Excessive Moisture and Dryness: Imbalances causing maceration or cracking.
- Personal Hygiene Behaviors: Over-bathing or harsh cleansers stripping skin oils.
Recognizing Signs and Symptoms
Key indicators of impaired skin integrity include:
- Pain: Discomfort or abnormal sensations.
- Inflammation: Redness, swelling, heat, and pain indicating immune response.
- Cutaneous Lesions: Abrasions, lacerations, ulcers, and other visible abnormalities.
- Loss of Cutaneous Substance (Wounds): Breaks in skin exposing deeper tissues.
- Skin and Tissue Color Changes: Redness, purple or black discoloration.
- Swelling Around Injury: Edema due to fluid accumulation.
- Pruritic/Itchy Skin: Persistent itching.
- Dry, Scaly Skin: Lack of moisture.
- Thin, Fragile Skin: Increased susceptibility to injury.
- Exudate or Drainage: Fluid leakage from wounds.
- Delayed Wound Healing: Slow or stalled healing process.
- Presence of Necrosis: Dead tissue indicating severe damage.
- Erythema: Persistent redness around wounds.
- Edema: Swelling from fluid retention.
Nursing Care Plans and Management
Effective wound care and skin integrity maintenance are fundamental in nursing. Nurses are crucial in managing wounds to promote healing and prevent complications. A tailored nursing care plan is essential, considering individual wound characteristics, health status, and preferences. Focus on wound assessment, interdisciplinary collaboration, patient education, and evidence-based practices optimizes outcomes and improves patient quality of life.
Nursing Priorities
Nursing priorities for patients with impaired skin integrity include:
- Wound Assessment: Regular assessment to determine treatment and promote healing.
- Effective Wound Care: High-quality care to minimize complications, readmissions, and costs, while improving patient well-being.
- Proper Suture and Staple Removal: Timely and correct removal to prevent complications.
- Drain Management: Ensuring effective drain function and preventing leakage.
- Burn Wound Care: Preventing deterioration of burn injuries.
- Pressure Injury/Ulcer Management: Prevention and treatment to reduce pain, morbidity, and healthcare costs.
- Patient and Caregiver Education: Empowering active participation in healing and prevention.
Nursing Assessment Details
Comprehensive skin and wound assessment includes measuring wound dimensions, evaluating the wound bed, identifying infection signs, and assessing surrounding skin integrity. This guides the selection of appropriate dressings, cleansing agents, and therapies.
Subjective and objective data indicating impaired tissue integrity:
- Affected area hot and tender to touch.
- Damaged or destroyed tissues.
- Local pain.
- Patient guarding the site.
- Skin and tissue color changes.
- Swelling around the injury.
- Itchy, dry, or fragile skin.
Nursing Diagnosis: Impaired Skin Integrity and Necrotizing Fasciitis Risk
Following assessment, nursing diagnoses are formulated. While the primary focus here is Impaired Skin Integrity, it’s vital for nurses to be vigilant about conditions that can escalate to severe infections like necrotizing fasciitis. Although “Necrotizing Fasciitis Nursing Diagnosis” isn’t a standalone NANDA-I diagnosis, it’s a critical consideration under the umbrella of impaired skin integrity and risk for infection.
Necrotizing fasciitis, a severe bacterial infection that destroys skin and soft tissues, often begins with seemingly minor skin injuries. Early nursing diagnosis is crucial. Nurses must assess for disproportionate pain, rapidly spreading erythema, edema, crepitus, and systemic signs of infection. A high index of suspicion and prompt intervention are life-saving. Therefore, while the general nursing diagnosis is Impaired Skin Integrity, the nursing focus in high-risk patients must include vigilant monitoring and assessment for the early signs of necrotizing fasciitis.
Examples of broader nursing diagnoses related to impaired skin integrity:
- Impaired Skin Integrity related to prolonged pressure on bony prominences as evidenced by redness and non-blanchable areas on sacrum and heels, patient report of pain and discomfort with repositioning secondary to CVA.
- Impaired Skin Integrity related to friction and shear from frequent repositioning.
- Impaired Skin Integrity related to insufficient nutritional intake as evidenced by delayed wound healing, dry and flaky skin.
Nursing Goals and Expected Outcomes
Goals for patients with impaired skin integrity include:
- Patient reports altered sensation or pain at the impairment site.
- Patient demonstrates understanding of tissue healing and injury prevention plan.
- Patient describes protective measures and wound care.
- Wound size decreases with increased granulation tissue.
Nursing Interventions and Actions
Therapeutic interventions for impaired skin integrity encompass:
1. Comprehensive Skin and Wound Assessment
Thorough assessment is fundamental for diagnosis and treatment. Visual skin examination and lesion description are key in diagnosing skin conditions (Kottner et al., 2020).
Determine Wound Etiology: Differentiating between acute, chronic, burns, dermatological lesions, pressure ulcers, or leg ulcers is crucial. Systemic diseases like diabetes significantly impact skin integrity (Kottner et al., 2020). In the context of “necrotizing fasciitis nursing diagnosis,” understanding the potential etiology – even seemingly minor breaks in skin – is critical for recognizing risk factors.
Assess Impaired Tissue Site: Redness, swelling, pain, burning, and itching indicate inflammation. Repeated irritant exposure and friction responses are also important to note (Kottner et al., 2020). In suspected necrotizing fasciitis, pay particular attention to disproportionate pain and rapidly spreading erythema, which are red flags.
Characterize the Wound: Document type, location, color, size, drainage, and odor. Use the Braden Scale to assess risk (Ernstmeyer & Christman, 2021).
- Type: Abrasions, lacerations, burns, surgical incisions, pressure injuries, ulcers.
- Location: Precise anatomical location.
- Size: Length, width, and depth measurements.
- Tissue Injury Degree: Partial or full thickness.
- Wound Base Color: Healthy granulation tissue, unhealthy slough, or necrotic tissue.
- Drainage: Color, consistency, and amount (serous, sanguineous, purulent).
Monitor Body Temperature: Fever is a systemic inflammation sign and may indicate infection (El-Radhi, 2019). In necrotizing fasciitis, fever is a significant systemic sign that, combined with local wound findings, heightens suspicion.
Assess Pain Level: Pain intensity may not always correlate with tissue damage extent (Ernstmeyer & Christman, 2021). Crucially, in necrotizing fasciitis, severe pain out of proportion to the wound appearance is a hallmark symptom.
Daily Site Monitoring: Check for color changes, redness, swelling, warmth, pain, and infection signs. Early detection is key to preventing systemic infection and sepsis (Ernstmeyer & Christman, 2021). For necrotizing fasciitis, rapid progression of these signs is characteristic and requires immediate attention.
Monitor Periwound Skin: Periwound skin condition provides insights into wound healing or deterioration (Ernstmeyer & Christman, 2021).
Evaluate Skin Care Practices: Note soap types, water temperature, and cleansing frequency. Individualized plans are necessary (Kottner et al., 2020).
Assess Overall Skin Condition: Baseline data for interventions. Healthy skin is warm, dry, and elastic with quick capillary refill. Age-related skin changes increase impairment risk.
History of Immunological Problems: Assess for conditions like AIDS, noting skin lesions like Kaposi sarcoma (American Cancer Society, 2018).
Radiation Therapy History: Radiated skin is thin, fragile, and at higher risk for breakdown (Nagle et al., 2022).
Evaluate Mobility Strength: Immobility is a major risk factor for skin breakdown (Ernstmeyer & Christman, 2021).
Assess Incontinence: Fecal/urinary incontinence hastens skin breakdown due to chemical irritation (Murphree, 2017).
Assess Edema: Edematous tissue is at risk due to taut skin and impaired circulation (Kottner et al., 2020).
Environmental Moisture: Wound drainage, humidity contribute to maceration (Murphree, 2017).
Dermatitis or Chemical Irritants: Exposure can cause inflammation and damage (Kottner et al., 2020).
Pruritus or Mechanical Trauma: Itching and scratching can disrupt skin integrity (Butler & James, 2023).
Signs of Steroid Use: Long-term steroid use thins skin, increasing injury risk (Nagle et al., 2022).
Factors Affecting Wound Healing: Local (blood flow, infection) and systemic (nutrition, diabetes, smoking) factors (Ernstmeyer & Christman, 2021).
Monitor Lab Values: Hemoglobin, WBC, glucose, wound cultures provide insights into healing impediments (Ernstmeyer & Christman, 2021).
2. Effective Skin and Wound Care
Protecting and enhancing skin integrity is paramount. Prevention is key. For vulnerable skin, create a safe environment.
Promoting Skin Integrity
Cleanse, Dry, Moisturize: Clean, dry, and moisturize skin, especially bony prominences, twice daily. Avoid hot water and talc powder (Kottner et al., 2020).
Massage Peripherally: Massage around affected areas to improve perfusion, not directly on reddened areas. Avoid massage on fragile skin or open wounds.
Incontinence Management: Implement a plan to prevent chemical exposure from urine and stool (Banharak et al., 2021).
Avoid Rubbing/Scratching: Prevent further injury; use gloves or trim nails.
Nutritional Status Assessment: Evaluate weight, weight loss, and albumin levels. Albumin <2.5 g/dL indicates high breakdown risk.
Nutritional Education: Emphasize fluids, protein, vitamins B and C, iron, and calories.
Dietary Recommendations: Encourage 2000-3000 kcal/day, high-protein, high-calorie diet as needed.
Hydration: Encourage 2000 mL/day fluid intake unless restricted.
Dietician Collaboration: Consult dietician for nutritional support.
Providing Wound Care
Wound Care as Needed: Tailor care to wound etiology. Dressings include wet/dry, topical creams, hydrocolloids, and vapor-permeable membranes.
Hand Hygiene: Essential before and after wound care to prevent infection.
Sterile Dressing Technique: Reduce infection risk with sterile field, gloves, supplies.
Premedicate for Pain: Manage pain during dressing changes with analgesics.
Wound Cleansing: Use appropriate solutions like normal saline, avoiding cytotoxic agents (Ernstmeyer & Christman, 2021).
Debridement Plan: Remove necrotic tissue (eschar or slough) if appropriate (Ernstmeyer & Christman, 2021).
Maintain Wound Moisture: Use dressings to maintain moist wound environment and manage exudate (Ernstmeyer & Christman, 2021).
Pack Deep Wounds: Pack appropriately to maintain moisture and eliminate dead space (Ernstmeyer & Christman, 2021).
Odor Control: Address wound odor with frequent dressing changes, cleansers, and antimicrobials (Ernstmeyer & Christman, 2021).
Periwound Skin Protection: Protect periwound skin from maceration with barrier creams (Ernstmeyer & Christman, 2021).
Antibiotic Administration: Administer as ordered; topical agents may be effective (Ernstmeyer & Christman, 2021). Options include:
- Polyhexamethylene biguanide (PHMB)
- Silver
- Iodine
- Methylene blue and crystal violet foam
- Honey (medical-grade)
Blister Management: Wrap with gauze or hydrocolloid dressing.
Wound Swabs: Prepare swabs for each dressing change if infection suspected.
Wound Vac Management: Assist with wound vac application and maintenance.
Advanced Topical Therapy: Consider topical growth factors, placental/umbilical cord tissue, acellular matrices, cell-based therapies for non-healing wounds.
3. Proper Suture and Staple Removal
Timing and technique are crucial to prevent complications.
Assess Wound Before Removal: Ensure wound closure and strength.
Irrigate Wound: Cleanse with sterile saline to remove debris and exudate.
Suture Removal Technique: Cut under knot close to skin, avoid pulling contaminated suture through tissue (Ernstmeyer & Christman, 2021).
Remove Remaining Sutures: Remove alternate sutures initially, then remaining if well-approximated (Doyle & McCutcheon, 2015).
Steri-Strips: Apply if separation occurs or after staple removal.
Staple Extractor Use: Use extractor correctly to avoid injury (Doyle & McCutcheon, 2015).
Handle Closed Extractor: Keep handle closed when moving extractor away from skin.
4. Drain Management
Essential for post-operative drainage, infection prevention, and healing.
Monitor Device Placement: Check tubes, catheters, drains, and tape integrity.
Hand Hygiene and PPE: Practice hygiene and use gloves, goggles during drain management (Ernstmeyer & Christman, 2021).
Drain Plug Removal: Use sterile technique, point plug away from face.
Drain Compression: Compress drain after emptying to re-establish vacuum.
Secure Device: Ensure proper placement and slack in tubing.
Drainage Tubing Removal: Remove with swift, steady motion.
Cleanse Drain Site: Cleanse old site and cover with sterile dressing.
WOCN Collaboration: Consult wound, ostomy, continence nurse for complex cases.
5. Burn Wound Management
Outpatient management is appropriate for minor burns not involving critical areas.
Burn Injury Assessment
ABCs Evaluation: Prioritize airway, breathing, circulation using ATLS protocol (Sheridan & Geibel, 2021).
Extent and Location: Assess burn extent and location, including corneal examination for facial burns.
Burn Size Estimation: Use Lund-Browder diagram or Rule of Nines for accurate estimation (Sheridan & Geibel, 2021).
Burn Depth Determination: Classify as first, second, third, or fourth degree.
- First-degree: Red, dry, painful.
- Second-degree: Red, wet, very painful, varying depth.
- Third-degree: Leathery, dry, insensate, waxy, requires grafting.
- Fourth-degree: Involves subcutaneous tissue, tendon, bone.
Infection Signs Assessment: Monitor for conversion to full-thickness, cellulitis, eschar separation, necrosis (Animalu & Chandrasekar, 2022).
Emergency Burn Management
Remove Flame Source: Stop, drop, and roll; smother flames.
Cooling Methods: Cool burned area with cool water, avoid ice.
Remove Restrictive Objects: Remove clothing and jewelry, leaving adherent clothing if cooled.
Cover Wound: Cover with clean, dry cloth. No ointments or salves.
Chemical Burn Irrigation: Irrigate chemical burns immediately.
Wound Cleaning and Dressing
Gentle Cleaning and Dressing: Cleanse debris and exudate regularly, usually daily (Sheridan & Geibel, 2021).
Proper Dressing Materials: Use viscous carrier dressings with broad-spectrum antibacterial properties (Sheridan & Geibel, 2021).
Pain Management: Premedicate for dressing changes as needed (Sheridan & Geibel, 2021).
Wet Dressings for Removal: Wet dressings with saline to ease removal.
Dressing Modifications: Adapt dressings to splints or positioning devices.
Excision and Grafting: Assist with excision and grafting for full-thickness burns.
Medication Administration
Topical Antibacterials: Apply as indicated; options include silver, silver nitrate, mafenide acetate, petrolatum, debriding enzymes.
Membrane Application: Assist with application of wound membranes (porcine xenograft, allograft, hydrocolloids, impregnated gauzes, Acticoat, Biobrane, Transcyte, Alloderm, Integra).
Surgical Burn Management
Debridement Assistance: Assist with natural, mechanical, chemical, or surgical debridement.
6. Pressure Injury Management
Prompt treatment is essential once pressure injuries develop.
Pressure Injury Assessment and Classification
Classify by Tissue Damage: Use NPIAP staging system.
- Stage I: Non-blanchable erythema.
- Stage II: Partial-thickness skin loss.
- Stage III: Full-thickness skin loss, subcutaneous tissue damage.
- Stage IV: Full-thickness skin loss, extensive damage to muscle, bone.
- Unstageable: Obscured by slough or eschar.
- Deep Tissue Pressure Injury: Persistent non-blanchable discoloration.
Check Bony Prominences: Sacrum, trochanters, scapulae, elbows, heels, malleoli, knees, back of head.
Evaluate Pressure Sensation Awareness: Assess patient’s ability to perceive and respond to pressure.
Objective Risk Assessment Tools: Use Braden Scale or Norton scale for risk assessment.
Shear and Friction Assessment: Evaluate shear and friction forces acting on skin.
Surface Assessment: Assess mattress, wheelchair cushions for pressure distribution.
Immobility Risk Assessment: Use mobility level scale to assess immobility-related risks.
Continence Status Monitoring: Minimize skin exposure to moisture from incontinence.
High-Risk Area Attention: Focus on bony prominences, skin folds, sacrum, heels.
Risk Factor Assessment: Immobility, sensory impairment, poor nutrition, etc.
Pressure Relief Measures
Device Placement Checks: Check footboards, restraints, traction, casts every 2 hours.
Pressure-Reducing Devices: Use pillows, foam wedges, pressure-reducing mattresses.
Head of Bed Elevation: Keep head of bed low to reduce shear.
Pressure-Relieving Device Implementation:
- Low-risk: Dense foam mattress overlay.
- Moderate-risk: Water mattress, static/dynamic air mattress.
- High-risk: Low-air-loss beds, air-fluidized therapy.
Encourage Ambulation: Promote ambulation to reduce pressure.
Improve Sensory Perception: Strategies to improve awareness and self-care.
Proper Patient Positioning
Avoid Positioning on Impaired Site: Do not position directly on pressure injury.
Repositioning Schedule: Turn every 2 hours, transfer carefully.
Chair Position Changes: Change chair-bound positions hourly, shift weight every 15 minutes.
Turning Schedule: Implement turning schedule in bed-bound patients.
Improve Tissue Perfusion: Activity, exercise, repositioning, avoid massage on erythematous areas.
Medical Pressure Injury Management
Hyperbaric Oxygen Therapy: Assist in preparing for hyperbaric oxygen therapy to promote healing.
Muscle Relaxants: Administer for spasticity; prepare for surgery if refractory.
Nutritional Supplementation: Provide oral nutritional supplements enriched with arginine, vitamin C, and zinc.
Surgical Pressure Injury Management
Surgical Procedures: Prepare for debridement, incision and drainage, bone resection, skin grafting for severe cases.
Urinary/Fecal Diversion: Assist with diversion procedures to optimize healing.
Pressure Injury Reconstruction: Prepare for reconstruction to improve hygiene, appearance, and prevent complications.
7. Patient and Caregiver Education
Empower patients and caregivers to actively participate in wound care and prevention.
Education on Nutrition, Hydration, Tissue Integrity: Educate on proper nutrition, hydration, and skin care.
Skin and Wound Assessment Education: Teach how to monitor for infection signs, complications, and healing progress.
Wound Care Instruction: Instruct on handwashing, cleansing, dressing changes, topical medication application.
Notify Healthcare Provider: Educate on when to seek professional help for complications.
Avoid Repeated Head Elevation: Discourage repeated head elevation in bed.
Pressure Cause Education: Explain causes of pressure injuries.
Turning, Mobility, Ambulation Importance: Reinforce the importance of movement.
Proper Skin Care Education: Teach skin care techniques for maintaining integrity.
Routine Pressure Area Inspection: Instruct on regular inspection of pressure areas.
Diaper/Incontinence Pad Checks: Emphasize regular checks and changes.
Environmental Factor Awareness: Alert caregivers to environmental factors contributing to pressure.
Home Support System: Ensure strong support system for ongoing management at home.
Recommended Resources
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
See also
Other recommended site resources for this nursing care plan:
References and Sources
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Animalu, C. I., & Chandrasekar, B. S. (2022). Burn wound cellulitis. In StatPearls [Internet]*. StatPearls Publishing.
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Banharak, M., Chayachinda, N., & Moriuchi, R. (2021). Effectiveness of containment devices for managing urinary and fecal incontinence in adults: an integrative review. International Wound Journal, 18(6), 837-850.
Butler, D. P., & James, W. D. (2023). Pruritus. In: James WD, Elston DM, Treat JR, Rosenbach MA, Neuhaus IM.
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El-Radhi, A. S. (2019). Fever management: evidence vs current practice. World Journal of Clinical Pediatrics, 8(3), 19.
Ernstmeyer, K., & Christman, M. (2021). Wound management. Wolters Kluwer Health/Lippincott Williams & Wilkins.
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Kirman, C. N., & Geibel, J. (2022). Pressure Ulcers. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL.
Kottner, J., Blume-Peytavi, U., Lohrmann, C., & Halfens, R. J. G. (2020). Skin integrity in the aged: a systematic review. British Journal of Dermatology, 183(2), 235-249.
Murphree, R. M. (2017). Moisture-associated skin damage: evidence-based prevention and treatment. Wound Management & Prevention, 63(11), 12-23.
Nagle, C., Ayoub, N., & Sharma, D. (2022). Factors Affecting Wound Healing.
Sheridan, R. L., & Geibel, J. (2021). Burns. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL.
