The skin, our body’s largest organ, acts as a crucial protective barrier against external threats, preventing pathogens from causing infections. When this barrier is compromised due to various factors like cuts, abrasions, ulcers, incisions, and wounds, it becomes vulnerable to bacterial invasion, potentially leading to infections and further complications. Therefore, a thorough 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 of impaired skin integrity, exploring its causes, signs and symptoms, assessment techniques, effective nursing interventions, and relevant care plans to guide nursing practice.
Causes of Impaired Skin Integrity
Impaired skin integrity can stem from a multitude of factors, broadly categorized as internal and external. Understanding these causes is crucial for targeted prevention and intervention strategies.
Internal Factors:
Internal factors originate within the body and can predispose individuals to skin integrity issues. These include:
- Extremes of Age: Both very young and elderly individuals have more fragile skin. Newborns have delicate, underdeveloped skin, while aging skin loses elasticity and becomes thinner, increasing susceptibility to injury.
- Cognitive Impairment: Patients with cognitive deficits may be unable to recognize or communicate discomfort or skin issues, leading to delayed intervention and potential skin breakdown.
- Physical Immobilization/Bedrest: Prolonged pressure on specific body areas due to immobility restricts blood flow, causing tissue ischemia and potential pressure injuries.
- Paralysis: Loss of motor function and sensation in paralyzed areas increases the risk of pressure injuries and skin damage due to immobility and lack of protective sensation.
- Poor Nutrition: Inadequate intake of essential nutrients like protein, vitamins, and minerals impairs skin regeneration and wound healing, making the skin more vulnerable to breakdown.
- Dehydration: Insufficient fluid intake leads to dry, less elastic skin that is more prone to cracks and injury.
- Underlying Medical Conditions: Certain conditions like diabetes mellitus, peripheral vascular disease, and autoimmune disorders can compromise circulation, sensation, and immune function, increasing the risk of impaired skin integrity.
External Factors:
External factors originate from the environment or external influences and directly impact skin health. These include:
- Hyperthermia: Elevated body temperature, such as in fever or heatstroke, can lead to increased perspiration and skin maceration, increasing vulnerability to breakdown.
- Hypothermia: Conversely, low body temperature can cause vasoconstriction and reduced blood flow to the skin, making it more susceptible to injury and delaying healing.
- Radiation: Exposure to radiation, whether from therapeutic radiation or excessive sun exposure, can damage skin cells, leading to burns, dryness, and impaired skin integrity.
- Chemicals: Exposure to harsh chemicals, irritants, or allergens can cause skin irritation, inflammation, and breakdown. This includes cleaning agents, solvents, and certain topical medications.
- Moisture/Secretions: Excessive moisture from perspiration, urine, stool, wound drainage, or saliva can lead to skin maceration, making it fragile and susceptible to breakdown, particularly in skin folds and perineal areas.
- Shearing/Friction/Pressure: Mechanical forces like shearing (skin layers sliding against each other), friction (rubbing against surfaces), and pressure (sustained compression) can damage the skin, especially over bony prominences.
- Medical Treatments: Surgery, incisions, wounds, and medical devices (casts, restraints) can directly compromise skin integrity.
Signs and Symptoms of Impaired Skin Integrity
Recognizing the signs and symptoms of impaired skin integrity is crucial for early identification and 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 pain in the affected skin area, ranging from mild soreness to severe pain, depending on the extent of tissue damage.
- Itching (Pruritus): An irritating sensation that provokes scratching, which can further damage the skin and increase the risk of infection.
- Numbness: Loss of sensation or altered sensation (tingling, pins and needles) in the affected and surrounding skin, indicating potential nerve damage or circulatory issues.
Objective Signs (Nurse Assesses):
- Changes to Skin Color:
- Erythema: Redness of the skin, indicating inflammation or increased blood flow to the area.
- Bruising (Ecchymosis): Discoloration of the skin due to blood leakage into subcutaneous tissues, often indicating trauma or pressure.
- Blanching: Paleness or whitening of the skin when pressure is applied, which may indicate impaired circulation or pressure damage. Non-blanchable erythema is a key sign of pressure injury.
- Warmth to Skin: Increased skin temperature in a localized area, often associated with inflammation or infection.
- Swelling to Tissues (Edema): Accumulation of fluid in the tissues, causing swelling, which can compromise skin integrity and circulation.
- Observed Open Areas or Breakdown: Visible disruptions in the skin surface, ranging from:
- Excoriation: Superficial skin abrasion or scraping.
- Erosion: Loss of epidermis, the outer layer of skin.
- Ulceration: Deeper skin loss extending into the dermis and potentially subcutaneous tissues, muscle, or bone.
- Laceration: A tear or jagged wound.
- Surgical Incision: A wound created intentionally during surgery.
Alt: Stage 2 Pressure Ulcer on Sacrum: Illustrates partial-thickness skin loss with exposed dermis.
Expected Outcomes for Impaired Skin Integrity
Establishing clear and measurable expected outcomes is essential for guiding nursing care and evaluating its effectiveness. Common goals and expected outcomes for patients with impaired skin integrity include:
- Patient will maintain intact skin integrity: Prevention is key. This outcome focuses on protecting the skin from further breakdown and preserving its integrity in at-risk individuals.
- Patient will experience timely healing of wounds without complications: For existing wounds, the goal is to promote efficient and complication-free healing, minimizing infection and maximizing tissue regeneration.
- Patient will demonstrate effective wound care: Empowering patients and caregivers to perform proper wound care techniques is crucial for ongoing management and preventing recurrence.
- Patient will verbalize proper prevention of pressure injuries: Educating patients and families about pressure injury prevention strategies is vital, especially for those at high risk due to immobility or other predisposing factors.
Nursing Assessment for Impaired Skin Integrity
A comprehensive nursing assessment is the cornerstone of effective care for impaired skin integrity. It involves gathering both subjective and objective data to identify risk factors, existing skin issues, and guide appropriate interventions.
1. Conduct a Thorough Skin Assessment: A systematic head-to-toe skin examination should be performed upon admission, during unit transfers, and at least once per shift. This routine assessment allows for early detection of skin changes and potential breakdown. Pay particular attention to high-risk areas such as bony prominences (heels, sacrum, elbows, hips), skin folds, and areas exposed to moisture.
2. Utilize Braden Skin Assessment Scale: Employ the Braden Scale, an evidence-based tool, to assess a patient’s risk for developing pressure injuries. This scale evaluates six key risk factors: sensory perception, moisture, activity, mobility, nutrition, friction, and shear. 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 use it whenever they suspect a risk of skin breakdown.
3. Assess Circulatory Status: Evaluate skin circulation, sensation, and turgor. Poor skin turgor (decreased elasticity), diminished sensation (indicating nerve damage), and impaired circulation (indicated by reddish or purple skin discoloration in lower legs and weak or absent pulses) significantly increase the risk of tissue injury. Assess peripheral pulses, capillary refill, skin color, and temperature.
4. Assess Activity Level and Mobility: Observe the patient’s ability to move and reposition themselves in bed and chair. Immobility or limited mobility is a major risk factor for pressure injuries. Patients who cannot ambulate or have difficulty shifting weight are at increased risk. Also, consider patients using restraints, as these can restrict movement and increase pressure on certain areas.
5. Determine Risk of Skin Breakdown Related to Moisture: Assess for factors contributing to excessive skin moisture, such as increased perspiration (diaphoresis) and incontinence (urinary or fecal). Evaluate the type and amount of body secretions present (sweat, urine, stool, wound drainage). Incontinence significantly elevates the risk of skin breakdown due to prolonged moisture exposure and skin irritation from urine and stool.
6. Evaluate Patient’s Ability for Self-Care: Determine the patient’s capacity to manage personal hygiene, including incontinence care and skin care. Patients who are incontinent or unable to request assistance for toileting require frequent monitoring and assistance to maintain clean, dry skin. Assess their ability to perform perineal care and apply barrier creams if needed.
7. Describe and Document Wounds Accurately: Precise documentation of observed wounds and skin breakdown is essential for monitoring healing progress and evaluating treatment effectiveness. Document wound location, size (length, width, depth), stage (if pressure injury), wound bed characteristics (color, granulation tissue, slough, eschar), drainage (type, color, amount, odor), periwound skin condition, presence of tunneling or undermining, and pain. Consider taking photographs for visual documentation and comparison over time, adhering to facility policies regarding patient privacy and consent.
8. Assess Patient’s Nutrition and Hydration Status: Monitor the patient’s nutritional intake and hydration levels. Adequate hydration is crucial for maintaining skin turgor and delivering oxygen and nutrients to wound sites. Protein is essential for tissue repair and regeneration. Assess dietary intake, including protein, vitamins (especially vitamin C and zinc), and fluid intake. Consider consulting a dietitian for nutritional assessment and recommendations, especially for patients with chronic wounds or malnutrition risk.
9. Assess Stoma and Ostomy Site (if applicable): For patients with ostomies, assess the stoma site regularly. A wound care specialist typically assesses newly created stomas to ensure proper healing and stoma viability (color, edema). Assess the appropriateness of the ostomy appliance and skin barrier to prevent peristomal skin irritation and breakdown. Monitor for signs of peristomal skin complications such as erythema, erosion, or maceration.
Alt: Nurse Assessing Ostomy Stoma: Close-up view of a nurse examining a healthy, pink stoma site.
Nursing Interventions for Impaired Skin Integrity
Nursing interventions are crucial for both preventing and treating impaired skin integrity. These interventions aim to minimize risk factors, promote skin healing, and prevent complications.
1. Implement Prescribed Wound Care Protocols: Apply appropriate wound care protocols based on the type, size, location, and stage of the wound. Wound care protocols should be guided by a wound care specialist’s recommendations or facility-specific policies and procedures. This may involve wound cleansing, debridement, application of topical medications or dressings (hydrogels, hydrocolloids, foams, alginates), and infection control measures.
2. Position and Reposition Patient Comfortably and Frequently: Protect bony prominences by relieving pressure. Reposition immobile patients at least every two hours, or more frequently as needed, following a turning schedule or using a turn clock as a reminder. Use pillows, wedges, and pressure-redistributing devices to support and offload bony prominences. Consider a 30-degree lateral position to reduce pressure on the sacrum and hips.
3. Ensure Adequate Skin Perfusion: Utilize pressure-redistributing support surfaces and positioning devices to promote adequate blood flow to the skin, especially over bony prominences. Use cushions, pillows, foam wedges, and specialty mattresses (low-air loss, air-fluidized) to distribute weight and reduce pressure on elbows, knees, hips, and heels. Avoid donut-shaped cushions, as they can concentrate pressure around the area.
4. Maintain Skin Hygiene and Manage Moisture: Keep the patient’s skin clean and dry. Gently cleanse the skin with mild, pH-balanced cleansers and warm water. Avoid harsh soaps and hot water, which can dry and irritate the skin. Pat skin dry thoroughly after cleansing, especially in skin folds. Implement a regular skin cleansing and moisturizing routine, particularly after episodes of incontinence or diaphoresis. Apply barrier creams or ointments to protect skin exposed to moisture, such as the perineal area.
5. Alleviate Pressure with Support Surfaces and Offloading Devices: Utilize pressure-redistributing mattresses and cushions to minimize pressure on bony prominences. Low-air loss mattresses cycle air to simulate patient movement and reduce pressure. Implement offloading techniques using wedge pillows, waffle boots, and gel overlays for chairs and beds to further reduce pressure on heels, elbows, and sacrum. Elevate heels off the bed using pillows or heel suspension devices.
6. Promote Proper Nutrition and Hydration: Encourage adequate nutritional intake and hydration. Collaborate with a dietitian to optimize the patient’s diet for wound healing. Ensure sufficient protein intake (1.25-1.5 g/kg of body weight), vitamins (especially A, C, E, and zinc), and minerals. Encourage fluid intake of 2-3 liters per day, unless contraindicated. Consider nutritional supplements if dietary intake is inadequate or if the patient has increased nutritional needs due to wound healing.
7. Protect Skin from Further Injury: Implement measures to protect the skin from friction, shear, and trauma. Ensure patients wear socks and non-slip shoes when ambulating. For patients with compromised neurovascular status, such as diabetic neuropathy, emphasize foot care and protection to prevent injuries due to reduced sensation. Pad splints, casts, and other medical devices to prevent pressure and friction.
8. Coordinate with Wound/Ostomy Specialist: Consult and collaborate with a wound care or ostomy specialist for complex wounds, ostomy care, and challenging skin integrity issues. A specialist can provide expert recommendations, evaluate wound progress, and guide appropriate wound care protocols and ostomy management.
9. Minimize Skin Irritation: Use barrier creams, pastes, or powders to minimize skin irritation from moisture, friction, and wound drainage. For ostomy care, utilize barrier pastes and powders around the stoma to protect peristomal skin from irritation and leakage. Use adhesive removers gently to minimize skin trauma during ostomy pouch changes. Avoid harsh adhesives and tape on fragile skin.
10. Manage Ostomy Pouch System Effectively: For patients with ostomies, provide education and support on proper ostomy pouch application, emptying, and skin care. Teach patients how to correctly size the adhesive wafer to fit the stoma, ensuring a proper seal to prevent leakage and peristomal skin irritation. Instruct patients to empty the ostomy pouch when it is ⅓ to ½ full to prevent excessive weight and potential pouch detachment or skin damage.
Alt: Nurse Performing Wound Dressing Change: Demonstrates aseptic technique during a dressing change procedure.
Nursing Care Plans for Impaired Skin Integrity
Nursing care plans provide a structured framework for prioritizing assessments and interventions to achieve both short-term and long-term care goals for patients with impaired skin integrity. Here are examples of nursing care plans addressing various aspects of impaired skin integrity.
Care Plan #1: Impaired Skin Integrity related to Immobility
Diagnostic statement:
Impaired skin integrity related to immobility as evidenced by stage 2 pressure ulcer to the sacrum.
Expected outcomes:
- Patient will experience improvement of pressure ulcer from stage 2 to improved healing stage within 1 month of nursing interventions.
- Patient will be able to maintain skin integrity by keeping the skin dry and clean at the end of each shift.
- Patient will verbalize cooperation and compliance during wound care within 1 hour of nursing intervention.
- Patient will enumerate ways to prevent pressure ulcers within 1 hour of nursing intervention.
Assessment:
1. Assess the skin and wounds regularly: Closely monitor skin at risk for breakdown at least once per shift, paying particular attention to bony prominences. Observe wounds to ensure dressings are intact and skin breakdown is not worsening (e.g., increased redness, drainage, size). Measure wounds at least weekly to monitor healing progress.
2. Determine the patient’s mobility: Assess the patient’s level of mobility and need for assistance with repositioning and movement. Immobility contributes to prolonged pressure on bony prominences, increasing pressure ulcer risk.
3. Assess the patient’s need for positioning devices: Evaluate the need for pressure-redistributing support surfaces and positioning devices to offload bony prominences in bedridden patients. Consider patient size and ability to move when selecting appropriate devices.
Interventions:
1. Perform wound care per guidelines and orders: Implement prescribed wound care protocols based on wound type, location, and size. Inadequate or incorrect wound care delays healing and increases infection risk.
2. Repositioning and support of bony prominences: Implement a turning schedule for patients unable to reposition themselves, turning them at least every 2 hours. Support bony prominences (hips, knees, heels, elbows) with pillows or pressure-redistributing devices to promote skin perfusion and reduce pressure.
3. Keep the skin clean and dry: Address incontinence or increased perspiration promptly. Assess for bodily secretions, especially near the wound. Keep bed linens, clothing, and incontinence products dry, as moisture irritates the skin and contributes to breakdown.
4. Use appropriate devices and air mattresses: Utilize wedge pillows, waffle boots, and gel overlays to offload pressure. Employ low-air loss mattresses that alternate inflation and deflation to mimic patient movement, aid repositioning, and relieve pressure.
5. Encourage nutrition and hydration: Promote adequate fluid intake to enhance oxygen and nutrient delivery to the wound bed by increasing blood volume. Encourage intake of high-protein foods and supplements to support tissue repair and regeneration.
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 to the left lower leg.
Expected outcomes:
- Patient will manifest intact skin on the lower extremities at the end of the shift.
- Patient will enumerate ways to prevent skin infection within 1 hour of nursing intervention.
- Patient will maintain skin perfusion by controlled blood glucose at the end of the shift.
- Patient will verbalize understanding of daily skin inspection within 1 hour of nursing intervention.
Assessment:
1. Assess skin for infection: Monitor the skin for signs of infection in areas of redness and open wounds, as these areas are at increased risk. Assess for redness, purulent drainage, warmth, foul odor, and swelling.
2. Determine skin perfusion: Assess skin perfusion in patients with diabetes, as they often have decreased sensation and impaired circulation due to diabetic neuropathy. These factors increase the risk of injury and delayed healing.
3. Monitor the patient’s blood glucose: Monitor blood glucose levels, as hyperglycemia impairs wound healing and increases infection risk in diabetic patients.
Interventions:
1. Control blood glucose: Maintain blood glucose levels within the target range to prevent worsening neuropathy, reduce infection risk, and promote wound healing.
2. Educate on diabetic neuropathy and the importance of daily skin checks: Educate patients about diabetic neuropathy, its impact on sensation, and the importance of daily skin inspections to identify injuries early, especially on the feet and lower legs.
3. Ensure foot protection at all times: Emphasize the need for foot protection at all times due to decreased sensation in the lower legs and feet. Advise wearing appropriate footwear, avoiding walking barefoot, and protecting feet from injury.
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 preventing skin irritation to skin surrounding the stoma within 1 hour of nursing intervention.
- Patient will manifest a moist and pinkish stoma at the end of the shift.
- Patient will enumerate ways to protect the stoma from skin breakdown within 1 hour of nursing intervention.
- Patient will verbalize the proper fitting and emptying of the ostomy pouch within 1 hour of nursing intervention.
Assessment:
1. Determine indication for surgery or stoma: Understand the underlying medical condition and pathophysiology that necessitated stoma creation to provide appropriate and individualized care.
2. Assess incision and stoma: Regularly assess the surgical incision and stoma site. A healthy stoma should be moist and pink-red, protruding slightly from the incision. Post-operative stoma swelling is expected but should gradually decrease.
3. Determine the patient’s diet: Assess the patient’s dietary intake, as nutrition and hydration are crucial for wound healing and stoma function. Refer to a dietitian for dietary evaluation and nutritional support, especially in the immediate post-operative period.
Interventions:
1. Collaborate with a wound/ostomy specialist: Involve a wound/ostomy specialist in the care of patients with new stomas to ensure proper stoma healing, appliance fitting, and patient education.
2. Create meal plans with the patient: Educate the patient on recommended dietary modifications to manage ostomy output and prevent complications. Initially, a low-residue diet is often prescribed to promote bowel healing. Discuss potential food sensitivities and strategies to manage diarrhea or constipation related to diet.
3. Minimize skin irritation: Encourage the use of barrier pastes and powders around the stoma to protect peristomal skin from irritation caused by stoma output. Teach proper application techniques. Recommend adhesive removers for gentle pouch removal to minimize skin trauma.
4. Educate the patient on properly fitting and emptying the ostomy pouch: Provide comprehensive education on ostomy pouch management, including proper wafer sizing, pouch application, emptying techniques (when ⅓ to ½ full), and skin care. Ensure patient demonstrates competency in pouch management before discharge.
Care Plan #4: Impaired Skin Integrity related to Burn Wounds
Diagnostic statement:
Impaired skin integrity related to burn wounds.
Expected outcomes:
- Patient will manifest skin restoration as evidenced by tissue regeneration within six months.
- Patient will maintain intact wound dressing at the end of the shift.
- Patient will verbalize cooperation and compliance during wound care at the end of the shift.
- Patient will enumerate ways to prevent skin infection within 1 hour of nursing intervention.
Assessment:
1. Assess the severity of the burn wound: Evaluate the extent and severity of the burn wound, as burn severity directly correlates with infection risk and healing time.
2. Determine the degree of burn: Determine the degree of burn (first, second, third, or fourth degree) to guide treatment and predict healing trajectory. Deeper burns (third and fourth degree) require more complex management and prolonged healing.
3. Assess the patient’s knowledge about wound dressing: Assess the patient’s understanding of burn wound care and dressing changes. Patient perception and anxiety about wound care can impact compliance and pain management.
Interventions:
1. Apply wound dressing: Apply appropriate wound dressings to protect the burn wound from infection and promote healing. Maintain aseptic technique during dressing changes due to the high risk of infection in burn patients.
2. Cleanse the wound regularly: Implement regular wound cleansing to remove debris and exudate, which can impede healing and increase infection risk. Wound debridement may be necessary to remove nonviable tissue and promote wound bed preparation for healing. Debridement techniques may include surgical, hydrosurgical, autolytic/enzymatic, mechanical, or biologic methods, depending on the burn characteristics and provider preference.
3. Promote new skin growth: Support skin tissue regeneration and new skin growth. Skin tissue engineering may be considered for extensive burns to promote more rapid and complete skin restoration. Ensure adequate blood flow and nutrition to the wound site to support tissue regeneration.
4. Encourage patient compliance in wound dressing: Address pain management effectively before dressing changes to improve patient comfort and cooperation. Educate the patient on the importance of wound dressing compliance for faster healing and infection prevention. Provide emotional support and address anxiety related to burn injuries and wound care.
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 skin irritation related to radiation therapy.
- Patient will alert the nurse to signs of worsening skin breakdown, such as peeling, open areas, or drainage.
Assessment:
1. Assess the skin prior to treatments: Assess skin integrity before each radiation treatment to monitor for early signs of radiation-induced skin reactions and breakdown.
2. Assess the patient’s understanding of normal vs. abnormal skin reactions: Educate the patient about expected skin reactions during radiation therapy (e.g., discoloration, dryness, itching). Explain the importance of reporting abnormal reactions (blisters, rash, open areas) to the healthcare team for prompt management.
Interventions:
1. Moisturize after treatments: Instruct the patient to apply non-irritating moisturizers to the treated area after each radiation session to maintain skin hydration and reduce dryness. Advise avoiding lotions immediately before treatment. Recommend fragrance-free and lanolin-free moisturizers to minimize allergic reactions.
2. Keep the skin clean and dry: Emphasize gentle skin hygiene. Advise using lukewarm water and mild soap for cleansing and patting the skin dry.
3. Do not use abrasive cleaners on the skin: Instruct the patient to avoid harsh soaps, antibacterial cleansers, and alcohol-based products, as these can dry and irritate the skin further. Advise against using washcloths or loofahs, recommending gentle hand washing.
4. Wear loose clothing and a comfortable bra: Recommend wearing loose-fitting, breathable cotton clothing to minimize friction and irritation in the treated area. If wearing a bra, suggest a soft, non-underwire bra.
5. Avoid direct sun exposure: Advise patients to protect radiation-treated skin from direct sun exposure, as it is more sensitive to UV radiation. Recommend covering the area with loose clothing or using non-irritating sunscreen as advised by the healthcare provider.
References
- Hyperthermia Nursing Diagnosis & Care Plan
- Acute Pain Nursing Diagnosis & Care Plan
- Wound Care & Infection Nursing Diagnosis & Care Plan
- Subjective vs. Objective Data in Nursing
- Nursing Interventions & Care
- Nursing Care Plans: A Guide
- Impaired Physical Mobility Nursing Diagnosis & Care Plan
- Pressure Ulcers Nursing Diagnosis & Care Plan
- Risk for Infection Nursing Diagnosis & Care Plan
- Ineffective Tissue Perfusion Nursing Diagnosis & Care Plan
- Diabetic Neuropathy Nursing Diagnosis & Care Plan
- Risk for Unstable Blood Glucose Nursing Diagnosis & Care Plan
- Diarrhea Nursing Diagnosis & Care Plan
- Anxiety Nursing Diagnosis & Care Plan
