The skin serves as the body’s primary defense, preventing pathogens from causing infections. However, when the skin is compromised due to various factors like cuts, abrasions, ulcers, incisions, and wounds, it becomes vulnerable to bacterial invasion and subsequent infections. For nurses, a thorough understanding of assessing, preventing, treating, and educating patients about compromised skin integrity is paramount in delivering optimal patient care. This article provides an in-depth guide to nursing diagnoses and skin care strategies for impaired skin integrity.
Common Causes of Impaired Skin Integrity
Impaired skin integrity can stem from a multitude of internal and external factors. Understanding these causes is crucial for effective prevention and treatment.
Internal Factors:
- Extremes in Age: Both very young and elderly individuals have more delicate and vulnerable skin.
- Cognitive Impairment: Patients with cognitive issues may be unable to communicate discomfort or reposition themselves, increasing pressure injury risk.
- Physical Immobilization/Bedrest: Prolonged pressure on specific areas reduces blood flow, leading to skin breakdown.
- Paralysis: Loss of mobility and sensation increases susceptibility to pressure injuries.
- Surgery: Surgical incisions disrupt skin integrity, creating potential entry points for infection.
- Wounds: Existing wounds, regardless of origin, compromise the skin’s protective barrier.
External Factors:
- Hyperthermia: Elevated body temperature can lead to increased perspiration and skin maceration.
- Hypothermia: Low body temperature can reduce circulation and make skin more fragile.
- Radiation: Radiation therapy can cause skin irritation, burns, and long-term damage.
- Chemicals: Exposure to harsh chemicals can irritate, burn, or erode the skin.
- Moisture/Secretions: Prolonged exposure to moisture from sweat, urine, or stool can lead to skin breakdown and infection.
- Shearing/Friction/Pressure: Mechanical forces can damage the skin, especially over bony prominences.
Recognizing Signs and Symptoms of Impaired Skin Integrity
Identifying impaired skin integrity early is vital for timely intervention. Assessment should include both subjective patient reports and objective nursing observations.
Subjective Symptoms (Patient Reports):
- Pain: Discomfort at the site of skin impairment.
- Itching: Irritation and pruritus in the affected area.
- Numbness: Loss of sensation in and around the compromised skin.
Objective Signs (Nurse Assesses):
- Changes in Skin Color: Erythema (redness), bruising, or blanching (pale skin upon pressure).
- Warmth to Skin: Increased temperature indicating inflammation or infection.
- Swelling to Tissues: Edema surrounding the area of impaired skin integrity.
- Observed Open Areas or Breakdown: Presence of lesions, excoriation, blisters, or wounds.
Expected Outcomes for Nursing Care
Setting clear goals for patient care is essential. For patients with impaired skin integrity, common expected outcomes include:
- Maintaining Intact Skin Integrity: Preventing further skin breakdown and promoting healthy skin.
- Timely Wound Healing: Facilitating efficient and complication-free wound closure.
- Effective Wound Care Practices: Patient and/or caregiver demonstrates proper wound management techniques.
- Pressure Injury Prevention: Patient verbalizes and demonstrates strategies to prevent pressure ulcers.
Comprehensive Nursing Assessment for Skin Integrity
A thorough nursing assessment is the cornerstone of effective skin care. It involves gathering both subjective and objective data to inform nursing diagnoses and interventions.
1. Systematic Skin Examination: Conduct a complete head-to-toe skin assessment upon admission, during transfers between units, and at least once per shift. This proactive approach helps in early detection and prevention of skin breakdown. Pay particular attention to high-risk areas like heels and the coccyx.
2. Braden Scale Assessment: Utilize the Braden Scale, an evidence-based tool, to assess pressure injury risk. This scale evaluates six key factors:
- Sensory Perception: Ability to sense 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: Potential for skin damage due to mechanical forces.
A Braden Scale score ranges from 6 to 23, with lower scores indicating higher risk. Institutional policies dictate the frequency of Braden Scale assessments, but nurses should also use it whenever they suspect a risk of skin breakdown.
3. Circulatory and Sensory Status: Assess skin circulation, sensation, and turgor. Poor skin turgor, diminished sensation (nerve damage), and impaired circulation (indicated by reddish or purple skin discoloration in lower legs and weak pulses) significantly increase tissue injury risk.
4. Activity and Mobility Evaluation: 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 limited movement.
5. Moisture-Related Skin Breakdown Risk: Assess factors contributing to skin moisture, such as excessive perspiration and incontinence. Evaluate body secretions including sweat, urine, and stool. Incontinence significantly elevates skin breakdown risk due to prolonged moisture exposure.
6. Self-Care Capacity Assessment: Determine the patient’s ability to manage incontinence and perform self-care. Patients unable to manage toileting or request assistance need vigilant monitoring to maintain dry, clean skin.
7. Wound Documentation and Description: Accurately document all observed wounds and skin breakdown. This is crucial for tracking healing progress and treatment effectiveness. Record wound length, width, depth, stage, drainage characteristics, periwound condition, odor, and presence of tunneling or undermining. Consider photographic documentation for comparative analysis.
8. Nutritional and Hydration Status: Evaluate the patient’s nutritional intake and hydration levels. Adequate hydration enhances oxygen and nutrient delivery to wound sites. Sufficient protein intake is essential for tissue repair and healing.
9. Stoma and Ostomy Assessment: For patients with new ostomies, assess stoma healing and the appropriateness of ostomy equipment. Wound care specialists typically perform this specialized assessment.
Nursing Interventions for Impaired Skin Integrity
Nursing interventions are crucial for both preventing and treating impaired skin integrity. These actions aim to protect the skin, promote healing, and prevent complications.
1. Implement Prescribed Wound Care Protocols: Follow established wound care protocols based on wound type, size, location, and healthcare facility guidelines. These protocols are often guided by wound care specialists and institutional policies.
2. Optimize Patient Positioning: Ensure comfortable positioning while protecting bony prominences from pressure. Reposition immobile patients at least every two hours or according to facility protocols. Utilize turn clocks as reminders for repositioning schedules.
3. Promote Skin Perfusion: Use cushions and positioning devices to support bony prominences such as elbows, knees, hips, and heels. This reduces pressure and enhances blood flow to these vulnerable areas.
4. Manage Moisture and Continence: Maintain clean, dry skin. Promptly address sweat, stool, and urine as these are skin irritants. Ensure dry clothing, bed linens, and perineal hygiene.
5. Pressure Redistribution: Utilize pressure-redistributing support surfaces such as low-air loss mattresses. These mattresses cycle inflation and deflation, simulating patient movement and reducing continuous pressure. Employ pressure-relief aids like wedge pillows, waffle boots, and gel overlays on chairs and beds.
6. Nutritional and Hydration Support: Promote adequate nutrition and hydration. Collaborate with dietitians to meet individual patient needs for optimal wound healing.
7. Skin Protection Measures: Implement skin protection strategies, such as encouraging sock and non-slip shoe use, particularly for patients with compromised neurovascular status like diabetics who have reduced sensation in their feet.
8. Wound and Ostomy Specialist Consultation: Collaborate with wound/ostomy specialists for expert recommendations, evaluations, and guidance on appropriate wound care protocols.
9. Minimize Skin Irritation: Use barrier pastes and powders to protect skin from irritation, especially around stomas or areas exposed to excessive moisture. Adhesive removers can facilitate pouch removal for ostomy patients without causing skin trauma.
10. Ostomy Pouch Management Education: Educate patients on proper ostomy pouch emptying and fitting techniques. Correctly sized adhesive wafers and pouch systems prevent leaks and peristomal skin irritation. Pouches should be emptied when they are one-third to one-half full to prevent detachment from the skin.
Nursing Care Plans for Impaired Skin Integrity
Nursing care plans provide structured frameworks for prioritizing assessments and interventions to achieve both short-term and long-term patient care goals. Here are examples of nursing care plans for impaired skin integrity based on different underlying causes.
Care Plan #1: Immobility-Related Impaired Skin Integrity
Diagnostic Statement: Impaired skin integrity related to immobility as evidenced by a stage 2 pressure ulcer on the sacrum.
Expected Outcomes:
- Pressure ulcer stage will improve from stage 2 to healed within 1 month of nursing interventions.
- Patient will maintain dry and clean skin throughout each shift.
- Patient will demonstrate cooperation and compliance with wound care within 1 hour of nursing intervention.
- Patient will list methods to prevent pressure ulcers within 1 hour of nursing intervention.
Assessments:
- Regular Skin and Wound Assessment: Monitor at-risk skin areas at least once per shift. Observe wounds for dressing integrity and signs of worsening skin breakdown. Measure wounds weekly to track progress.
- Mobility Assessment: Determine the patient’s level of assistance needed for movement. Immobility contributes to prolonged pressure and pressure ulcer formation.
- Positioning Device Needs: Evaluate the need for positioning devices to offload bony prominences in bedridden patients. Consider patient size and mobility level to select appropriate devices.
Interventions:
- Wound Care as Prescribed: Implement wound care protocols based on skin breakdown type, location, and size. Inadequate wound care delays healing and increases infection risk.
- Repositioning and Bony Prominence Support: Turn immobile patients at least every 2 hours. Support bony prominences (hips, knees, heels, elbows) with pillows or devices to promote skin perfusion.
- Maintain Clean and Dry Skin: Address incontinence and perspiration promptly. Assess for bodily secretions, especially near wounds. Keep bed linens, clothing, and incontinence products dry to prevent skin irritation.
- Utilize Support Surfaces and Devices: Employ wedge pillows, waffle boots, gel overlays, and low-air loss mattresses to offload pressure effectively.
- Promote Nutrition and Hydration: Encourage adequate fluid intake to improve oxygen and nutrient delivery to the wound bed. Ensure sufficient protein intake for tissue repair.
Care Plan #2: Diabetic Neuropathy-Related Impaired Skin Integrity
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 the end of each shift.
- Patient will list ways to prevent skin infection within 1 hour of nursing intervention.
- Patient will maintain skin perfusion through controlled blood glucose levels by the end of each shift.
- Patient will verbalize understanding of daily skin inspection within 1 hour of nursing intervention.
Assessments:
- Infection Assessment: Assess skin for signs of infection (redness, purulent drainage, warmth, odor, swelling). Diabetic patients are at high risk for infections like cellulitis.
- Skin Perfusion Assessment: Evaluate skin perfusion. Diabetic neuropathy reduces sensation and blood flow, increasing injury risk due to delayed pain perception and compromised healing.
- Blood Glucose Monitoring: Monitor blood glucose levels. Hyperglycemia impairs wound healing and increases infection susceptibility in diabetic patients.
Interventions:
- Blood Glucose Control: Maintain blood glucose within target ranges to prevent neuropathy progression, reduce infection risk, and promote wound healing.
- Diabetic Neuropathy and Skin Check Education: Educate patients about diabetic neuropathy symptoms (numbness, reduced sensation) and the importance of daily skin inspections to detect injuries early.
- Foot Protection: Emphasize the need for consistent foot protection to prevent skin injuries due to decreased sensation in lower legs and feet.
Care Plan #3: Surgical Incision and Stoma-Related Impaired Skin Integrity
Diagnostic Statement: Impaired skin integrity related to surgical incision and stoma creation on the abdomen.
Expected Outcomes:
- Patient will verbalize methods to prevent skin irritation around the stoma within 1 hour of nursing intervention.
- Patient will exhibit a moist and pink stoma at the end of each shift.
- Patient will list ways to protect the stoma from skin breakdown within 1 hour of nursing intervention.
- Patient will verbalize proper ostomy pouch fitting and emptying techniques within 1 hour of nursing intervention.
Assessments:
- Surgical Indication and Stoma Purpose: Understand the underlying condition necessitating surgery and stoma creation to provide informed care.
- Incision and Stoma Assessment: Assess the surgical incision and stoma characteristics. A healthy stoma should be moist, pink-red, and slightly protruding, although initial swelling is expected post-surgery.
- Dietary Assessment: Evaluate the patient’s diet, as nutrition and hydration play a vital role in surgical and stoma site recovery. Consult a dietitian for nutritional support.
Interventions:
- Wound/Ostomy Specialist Collaboration: Consult with wound/ostomy specialists to ensure proper stoma healing, appropriate ostomy supplies, and patient education.
- Meal Planning and Dietary Guidance: Educate patients on dietary recommendations to manage ostomy output. Initially, a low-residue diet is prescribed for bowel healing. Advise limiting spicy foods, alcohol, and high-fiber foods that can cause diarrhea.
- Skin Irritation Minimization: Encourage the use of barrier pastes and powders to protect peristomal skin from irritation and leakage. Utilize adhesive removers for gentle pouch removal.
- Ostomy Pouch Education: Educate patients on correct ostomy pouch fitting and emptying. Proper wafer sizing and pouch system application prevent leakage and skin irritation. Instruct patients to empty pouches when one-third to one-half full.
Care Plan #4: Burn Wound-Related Impaired Skin Integrity
Diagnostic Statement: Impaired skin integrity related to burn wounds.
Expected Outcomes:
- Patient will demonstrate skin restoration as evidenced by tissue regeneration within six months.
- Patient will maintain intact wound dressings at the end of each shift.
- Patient will demonstrate cooperation and compliance during wound care at the end of each shift.
- Patient will list methods to prevent skin infection within 1 hour of nursing intervention.
Assessments:
- Burn Wound Severity Assessment: Assess the severity of the burn wound to determine infection risk. Burns compromise the skin’s protective barrier, increasing infection vulnerability.
- Burn Degree Determination: Determine the burn degree (first, second, third, or fourth) to classify the depth of skin damage and guide treatment. Fourth-degree burns are the most severe, involving subcutaneous tissue, tendon, and bone.
- Patient Knowledge of Wound Dressing: Assess the patient’s understanding of burn wound dressing and its importance for treatment adherence. Burn wound care can be painful and lengthy, requiring frequent dressing changes to prevent infection.
Interventions:
- Wound Dressing Application: Apply appropriate wound dressings to protect the burn site, prevent infection, and promote healing. Maintain aseptic technique due to high infection risk in burn patients.
- Regular Wound Cleansing: Cleanse wounds regularly to remove debris and exudates that impede healing. Wound debridement (surgical, hydrosurgical, autolytic/enzymatic, mechanical, biologic) promotes tissue regeneration and optimal wound healing.
- Promote Skin Growth: Implement skin tissue engineering strategies to promote new skin growth in burn areas. Good blood flow is essential for successful skin regeneration.
- Enhance Patient Compliance with Wound Dressing: Address pain management before dressing changes to improve patient comfort and cooperation. Educate patients on the importance of wound care compliance for faster healing and infection prevention.
Care Plan #5: Radiation Therapy-Related Impaired Skin Integrity
Diagnostic Statement: Impaired skin integrity related to radiation therapy as evidenced by erythema and patient reports of irritation in the axillary area.
Expected Outcomes:
- Patient will verbalize two interventions to prevent skin irritation.
- Patient will promptly report signs of 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 breakdown or infection signs.
- Patient Understanding of Skin Reactions: Evaluate the patient’s understanding of expected and abnormal skin reactions to radiation. Mild skin irritation, discoloration (sunburn-like), dryness, itching, and puffiness are common. Blisters or rash require prompt reporting to the healthcare team.
Interventions:
- Post-Treatment Moisturizing: Instruct patients to moisturize the treated area between radiation sessions. Avoid lotion application immediately before treatment. Recommend fragrance-free and lanolin-free moisturizers to prevent allergic reactions.
- Maintain Clean and Dry Skin: Emphasize hygiene to prevent further irritation and infection. Use warm water and mild soap for cleansing and ensure the area is thoroughly dried.
- Avoid Abrasive Skin Products: Advise against using antibacterial soaps or alcohol-based products that can dry the skin. Use gentle washing techniques, avoiding washcloths or loofahs.
- Loose Clothing and Comfortable Bra: Recommend loose, breathable cotton clothing. If wearing a bra, choose a non-underwire style for comfort and reduced friction.
- Sun Exposure Avoidance: Advise patients to avoid direct sun exposure to radiation-treated skin, as it is more sensitive to UV rays. Protect the area with loose clothing or non-irritating sun protection as recommended by the healthcare provider.
References
- Hyperthermia Nursing Diagnosis and Care Plan
- Acute Pain Nursing Diagnosis and Care Plan
- Wound Care and Infection Nursing Diagnosis and Care Plan
- Subjective vs. Objective Data in Nursing
- Nursing Interventions Guide
- Nursing Care Plans: A Comprehensive Guide
- Impaired Physical Mobility Nursing Diagnosis and Care Plan
- Pressure Ulcers (Pressure Injury) Nursing Diagnosis and Care Plan
- Risk for Infection Nursing Diagnosis and Care Plan
- Ineffective Tissue Perfusion Nursing Diagnosis and Care Plan
- Diarrhea Nursing Diagnosis and Care Plan
- Diabetic Neuropathy Nursing Diagnosis and Care Plan
- Risk for Unstable Blood Glucose Nursing Diagnosis and Care Plan
- Anxiety Nursing Diagnosis and Care Plan
