The skin, our body’s first line of defense, is crucial in preventing pathogens from causing infections and illnesses. When this protective barrier is compromised due to injuries like cuts, abrasions, ulcers, incisions, and wounds, it becomes a gateway for bacteria, leading to infections. Therefore, a comprehensive understanding of assessing, preventing, treating, and educating patients about impaired skin integrity is paramount for nurses.
In this article, we will delve into the nursing diagnosis and care plan for impaired skin integrity, providing a detailed guide for healthcare professionals.
Causes of Impaired Skin Integrity
Impaired skin integrity can stem from a variety of factors, broadly categorized as internal and external causes:
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 less aware of injuries or unable to communicate discomfort, leading to prolonged pressure or neglect of skin issues.
- Paralysis: Loss of mobility due to paralysis significantly increases the risk of pressure injuries as patients are unable to reposition themselves.
- Physical Immobilization/Bedrest: Prolonged bed rest or limited mobility concentrates pressure on certain areas, reducing blood flow and increasing the risk of skin breakdown.
External Factors:
- Hyperthermia: Elevated body temperature can lead to increased perspiration and moisture, predisposing the skin to breakdown.
- Hypothermia: Low body temperature can reduce circulation and make the skin more susceptible to injury.
- Radiation: Radiation therapy can damage skin cells, leading to dryness, irritation, and impaired integrity.
- Chemicals: Exposure to harsh chemicals can cause skin irritation, burns, and breakdown.
- Surgery: Surgical incisions disrupt skin integrity and create a potential entry point for infection.
- Wounds: Pre-existing wounds naturally indicate impaired skin integrity and require careful management to prevent further damage and infection.
- Moisture/Secretions: Excessive moisture from sweat, urine, stool, or wound drainage can macerate the skin, making it fragile and prone to breakdown.
- Shearing/Friction/Pressure: Forces like shearing (skin layers sliding over each other), friction (rubbing against surfaces), and prolonged pressure (especially over bony prominences) are major contributors to pressure injuries and skin damage.
Signs and Symptoms of Impaired Skin Integrity
Recognizing the signs and symptoms of impaired skin integrity is crucial for timely intervention. These manifestations can be both subjective (reported by the patient) and objective (observed by the nurse).
Subjective Symptoms (Patient Reports):
- Pain: Discomfort or soreness in the affected skin area.
- Itching: Pruritus or an irritating sensation that provokes scratching, potentially further damaging the skin.
- Numbness: Loss of sensation in the affected or surrounding skin, indicating nerve involvement or reduced blood flow.
Objective Signs (Nurse Assesses):
- Changes to Skin Color:
- Erythema: Redness of the skin, indicating inflammation or increased blood flow.
- Bruising: Discoloration due to blood leakage under the skin, often from trauma or pressure.
- Blanching: Pale or white skin when pressure is applied, which can indicate impaired circulation.
- Warmth to Skin: Increased temperature in the affected area, often associated with inflammation or infection.
- Swelling to Tissues (Edema): Fluid accumulation in the tissues, potentially indicating inflammation or circulatory issues.
- 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, often appearing as linear or superficial abrasions.
Expected Outcomes for Impaired Skin Integrity
Effective nursing care planning for impaired skin integrity aims to achieve the following outcomes:
- Patient will maintain intact skin integrity, preventing further breakdown.
- Patient will experience timely and effective healing of existing wounds without complications such as infection.
- Patient will demonstrate proficiency in wound care techniques and adhere to the prescribed regimen.
- Patient will verbalize understanding of pressure injury prevention strategies and implement them in daily life.
Nursing Assessment for Impaired Skin Integrity
A thorough nursing assessment is the cornerstone of developing an effective care plan. It involves gathering both subjective and objective data to understand the patient’s condition comprehensively.
1. Conduct a Comprehensive Skin Assessment:
A head-to-toe skin examination is essential upon admission, during unit transfers, and at least once per shift. This proactive approach allows for early detection and prevention of skin breakdown. Pay close attention to high-risk areas such as heels, sacrum, and bony prominences.
2. Utilize the Braden Scale for Pressure Injury Risk Assessment:
The Braden Scale is an evidence-based tool to assess a patient’s risk of developing pressure injuries. It evaluates six key criteria:
- Sensory Perception: Ability to feel and respond to discomfort or pressure.
- Moisture: Degree of skin wetness due to perspiration, incontinence, or wound drainage.
- Activity: Level of physical activity and ability to move.
- Mobility: Ability to change and control body position independently.
- Nutrition: Usual food intake pattern and nutritional status.
- Friction and Shear: Risk of skin damage due to friction and shearing forces.
A score is calculated, ranging from 6 to 23, with lower scores indicating a higher risk of pressure injury. The frequency of Braden Scale assessments should align with institutional policy and clinical judgment, especially when risk factors are present.
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, and weak pulses) all increase the risk of tissue injury.
4. Evaluate Activity Level and Mobility:
Observe the patient’s ability to ambulate and reposition themselves in bed or chair. Immobility is a significant risk factor for skin breakdown. Also, consider patients using restraints, as they are at increased risk due to restricted movement.
5. Determine Moisture-Related Skin Breakdown Risk:
Assess for factors that increase skin moisture, such as excessive perspiration and incontinence. Evaluate body secretions including:
- Sweat/Perspiration
- Urine
- Stool
Incontinent patients are particularly vulnerable to skin breakdown due to prolonged exposure to moisture.
6. Evaluate Self-Care Ability:
Assess the patient’s capacity to manage incontinence and perform self-care activities. Patients who are incontinent or require assistance with toileting need frequent monitoring to maintain skin dryness and cleanliness.
7. Describe and Document Wounds Thoroughly:
Accurate documentation of wounds and skin breakdown is crucial for monitoring healing progress and treatment effectiveness. Record detailed descriptions of wound characteristics:
- Location
- Size (length, width, depth)
- Stage (if applicable, for pressure ulcers)
- Wound bed characteristics (color, tissue type)
- Drainage (type, color, amount, odor)
- Periwound skin (condition of skin surrounding the wound)
- Tunneling or Undermining (if present)
Photography is recommended for visual documentation and comparative assessment over time.
8. Assess Nutritional and Hydration Status:
Monitor the patient’s dietary intake and fluid balance. Adequate hydration and nutrition are essential for tissue repair and wound healing. Focus on protein intake, as it is vital for tissue regeneration.
9. Assess Stoma and Ostomy Sites:
For patients with new ostomies, assess the stoma site regularly. A wound care specialist typically evaluates stoma healing and the appropriateness of ostomy equipment.
Image: A nurse carefully examines a patient’s sacral area for signs of pressure ulcers, highlighting the importance of thorough skin assessments in preventing skin breakdown.
Nursing Interventions for Impaired Skin Integrity
Nursing interventions are crucial in both preventing and treating impaired skin integrity.
1. Implement Prescribed Wound Care Protocols:
Apply wound care protocols tailored to the wound type, size, and location. These protocols should be guided by wound care specialist recommendations and facility policies.
2. Optimize Patient Positioning for Comfort and Pressure Relief:
Protect bony prominences from pressure. Reposition immobile patients at least every two hours, or more frequently according to facility protocols. Utilize a turn clock as a reminder for repositioning schedules.
3. Promote Adequate Skin Perfusion:
Use cushions, pillows, and specialized positioning devices to support bony prominences such as:
- Elbows
- Knees
- Hips
- Heels
4. Manage Continence and Skin Moisture:
Maintain clean, dry skin. Promptly address incontinence and excessive perspiration. Keep clothing, bed linens, and the perineal area dry to minimize skin irritation from moisture.
5. Alleviate Pressure with Support Surfaces:
Utilize pressure-redistributing support surfaces like low-air loss mattresses. These mattresses cycle inflation and deflation, mimicking natural body movement and reducing pressure points. Other helpful devices include:
- Wedge Pillows
- Waffle Boots
- Gel Overlays for chairs and beds
6. Promote Optimal Nutrition and Hydration:
Encourage a balanced diet and adequate fluid intake. Collaborate with a dietitian to ensure the patient’s nutritional needs are met to support tissue healing.
7. Protect Skin from Further Injury:
Implement measures to protect vulnerable skin. Encourage patients to wear socks and non-slip shoes, especially those with compromised neurovascular status like diabetic patients, who may have reduced sensation in their feet.
8. Consult with Wound/Ostomy Specialist:
Collaborate with a wound care or ostomy specialist for expert guidance on complex wound management and ostomy care. They can provide specialized recommendations and training.
9. Minimize Skin Irritation:
Use barrier creams, pastes, and powders to protect skin from irritants, especially in areas prone to moisture or around stomas. Adhesive removers can facilitate pouch removal for ostomy patients without causing skin damage.
10. Manage Ostomy Pouches Effectively:
Educate patients on proper ostomy pouch management, including emptying and fitting techniques. Correctly sized adhesive wafers and pouch systems are essential to prevent leaks and peristomal skin irritation. Pouches should be emptied when they are one-third to one-half full to prevent excessive weight and potential detachment from the skin.
Image: A nurse expertly demonstrates wound care techniques, emphasizing the practical application of nursing interventions for impaired skin integrity.
Nursing Care Plans for Impaired Skin Integrity
Nursing care plans provide structured frameworks for prioritizing assessments and interventions, guiding both short-term and long-term care goals. Here are examples of nursing care plans for impaired skin integrity:
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 the pressure ulcer from stage 2 to improved healing within a specified timeframe (e.g., within 1 month of nursing interventions).
- Patient will maintain dry and clean skin at the end of each shift.
- Patient will demonstrate cooperation and compliance with wound care during nursing interventions.
- Patient will verbalize understanding of pressure ulcer prevention methods within a specified timeframe (e.g., within 1 hour of nursing intervention).
Assessment:
1. Regular Skin and Wound Assessment: Monitor at-risk skin areas at least once per shift. Observe wounds for signs of worsening breakdown, such as increased redness or drainage. Measure wounds weekly to track progress.
2. Mobility Assessment: Determine the patient’s level of mobility and need for assistance with movement. Immobility increases pressure on bony prominences.
3. Need for Positioning Devices: Assess the patient’s need for pillows or specialized devices to offload bony prominences and maintain proper positioning.
Interventions:
1. Wound Care as Prescribed: Implement wound care protocols based on wound type, location, and size, following guidelines and orders. Proper wound care is crucial for healing and preventing infection.
2. Repositioning and Bony Prominence Support: Reposition immobile patients at least every 2 hours. Support bony prominences with pillows or devices to promote skin perfusion and pressure relief.
3. Maintain Clean and Dry Skin: Address incontinence and perspiration promptly. Keep bed linens, clothing, and perineal area dry to prevent skin irritation.
4. Utilize Support Surfaces: Use appropriate support surfaces like wedge pillows, waffle boots, gel overlays, and low-air loss mattresses to redistribute pressure.
5. Promote Nutrition and Hydration: Encourage adequate fluid intake and a diet rich in protein to support tissue repair and 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 maintain intact skin on lower extremities at the end of each shift.
- Patient will enumerate methods to prevent skin infection within a specified timeframe (e.g., within 1 hour of nursing intervention).
- Patient will maintain adequate skin perfusion through controlled blood glucose levels by the end of each shift.
- Patient will verbalize understanding of the importance of daily skin inspection within a specified timeframe (e.g., within 1 hour of nursing intervention).
Assessment:
1. Assess for Skin Infection: Monitor for signs of infection in areas of skin breakdown, such as redness, purulent drainage, warmth, odor, and swelling, as diabetic patients are at increased risk.
2. Evaluate Skin Perfusion: Assess skin perfusion, noting that diabetic neuropathy can impair sensation and blood flow, increasing injury risk.
3. Monitor Blood Glucose Levels: Regularly monitor blood glucose, as hyperglycemia can impair wound healing and increase infection risk in diabetic patients.
Interventions:
1. Blood Glucose Control: Maintain blood glucose within the target range to prevent neuropathy progression, reduce infection risk, and promote wound healing.
2. Educate on Diabetic Neuropathy and Skin Checks: Educate the patient about diabetic neuropathy, its impact on sensation, and the critical need for daily skin inspections to identify injuries early.
3. Ensure Foot Protection: Emphasize the importance of wearing protective footwear at all times to prevent foot injuries due to reduced 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 irritation prevention within a specified timeframe (e.g., within 1 hour of nursing intervention).
- Patient will exhibit a moist and pinkish stoma at the end of each shift, indicating healthy stoma viability.
- Patient will enumerate methods to protect the stoma from skin breakdown within a specified timeframe (e.g., within 1 hour of nursing intervention).
- Patient will demonstrate proper ostomy pouch fitting and emptying techniques within a specified timeframe (e.g., within 1 hour of nursing intervention).
Assessment:
1. Determine Indication for Surgery/Stoma: Understand the underlying medical condition necessitating surgery and stoma creation to tailor care appropriately.
2. Incision and Stoma Assessment: Assess the surgical incision and stoma characteristics. A healthy stoma should be moist, pink-red, and slightly protruding.
3. Dietary Assessment: Evaluate the patient’s diet and hydration status, as nutrition plays a vital role in wound healing and stoma function.
Interventions:
1. Wound/Ostomy Specialist Collaboration: Consult with a wound/ostomy specialist for expert assessment, education, and guidance on stoma care and appropriate ostomy supplies.
2. Meal Planning and Dietary Education: Collaborate with a dietitian and educate the patient on dietary modifications to manage ostomy output and promote bowel healing.
3. Minimize Skin Irritation around Stoma: Encourage the use of barrier pastes and powders to protect peristomal skin from irritation and leakage.
4. Ostomy Pouch Education: Educate the patient on proper ostomy pouch fitting, emptying frequency (when ⅓ to ½ full), and techniques to ensure a secure seal and prevent skin irritation.
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 with tissue regeneration within a reasonable timeframe (e.g., within six months).
- Patient will maintain intact wound dressings at the end of each shift, protecting the burn site.
- Patient will demonstrate cooperation and compliance with wound care regimens throughout the shift.
- Patient will enumerate methods to prevent skin infection related to burn wounds within a specified timeframe (e.g., within 1 hour of nursing intervention).
Assessment:
1. Burn Wound Severity Assessment: Assess the severity and extent of the burn wound to determine infection risk and guide treatment.
2. Burn Degree Determination: Classify the burn degree (first, second, third, or fourth) to understand the depth of tissue damage and guide appropriate care.
3. Patient Knowledge of Wound Dressing: Assess the patient’s understanding of burn wound dressing procedures and their expectations for treatment and healing.
Interventions:
1. Wound Dressing Application: Apply appropriate wound dressings using aseptic technique to protect the burn site, prevent infection, and promote healing.
2. Regular Wound Cleansing: Cleanse the wound regularly to remove debris and exudate, promoting wound healing. Debridement techniques may be necessary to remove non-viable tissue.
3. Promote New Skin Growth: Implement strategies to promote skin regeneration. Skin tissue engineering may be considered in severe cases.
4. Encourage Patient Compliance: Address pain management needs and educate the patient on the importance of wound dressing compliance for optimal 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 in the axillary area.
Expected Outcomes:
- Patient will verbalize two interventions to prevent skin irritation related to radiation therapy.
- Patient will promptly report signs of worsening skin breakdown, such as peeling, open areas, or drainage, to the nurse.
Assessment:
1. Pre-Treatment Skin Assessment: Assess skin integrity before each radiation treatment to monitor for changes or breakdown.
2. Patient Understanding of Skin Reactions: Assess the patient’s understanding of expected skin reactions to radiation and when to report abnormal changes.
Interventions:
1. Post-Treatment Moisturizing: Instruct the patient to moisturize the treated area after each radiation session with fragrance-free, lanolin-free moisturizers. Avoid application immediately before treatment.
2. Maintain Clean and Dry Skin: Advise the patient to keep the treated skin clean and dry using warm water and mild soap. Pat dry gently.
3. Avoid Abrasive Cleaners: Instruct the patient to avoid antibacterial soaps, alcohol-based products, and harsh scrubbing, which can further irritate the skin.
4. Loose Clothing and Comfortable Bra: Recommend loose, breathable cotton clothing and bras without underwires to minimize friction and irritation.
5. Sun Protection: Advise the patient to avoid direct sun exposure to the treated area and use non-irritating sun protection as recommended by their healthcare provider.
