Patient Plan of Care for Nursing Diagnosis Impaired Skin Integrity

The skin, our body’s largest organ, acts as a vital protective barrier against the external environment, shielding us from pathogens and injury. When this barrier is compromised due to various insults such as cuts, abrasions, ulcers, surgical incisions, and wounds, it becomes vulnerable to bacterial invasion and subsequent infections. Therefore, a thorough understanding of how to assess, prevent, manage, and educate patients about impaired skin integrity is paramount for nurses and healthcare professionals.

This article provides a comprehensive guide to developing a patient plan of care for the nursing diagnosis of impaired skin integrity. We will delve into the causes, signs and symptoms, essential nursing assessments, evidence-based interventions, and tailored care plans to promote optimal skin health and wound healing.

Causes (Etiology) of Impaired Skin Integrity

Impaired skin integrity arises from a multitude of factors, which can be broadly categorized as internal and external. Understanding these underlying causes is crucial for targeted prevention and intervention strategies.

Internal Factors:

• Extremes of Age: Both very young and elderly individuals are at increased risk. Neonates have delicate, underdeveloped skin, while older adults experience age-related skin changes such as thinning, decreased elasticity, reduced subcutaneous fat, and diminished immune function, making their skin more susceptible to injury and slower to heal.
• Cognitive Impairment: Patients with cognitive deficits may be unable to recognize or communicate discomfort, or take preventative measures, increasing their risk for pressure injuries and skin breakdown due to prolonged pressure or friction.
• Chronic Medical Conditions: Certain systemic diseases significantly impair skin integrity.
  • Diabetes Mellitus: Diabetic neuropathy can lead to decreased sensation, particularly in the extremities, making patients unaware of injuries. Poor circulation associated with diabetes also hinders wound healing.
  • Peripheral Vascular Disease (PVD): Reduced blood flow in PVD compromises oxygen and nutrient delivery to the skin, increasing vulnerability to ischemia and ulceration, especially in the lower extremities.
  • Immunodeficiency: Conditions that weaken the immune system, such as HIV/AIDS or immunosuppressive therapies, increase susceptibility to skin infections and delayed wound healing.
  • Malnutrition: Inadequate protein, vitamins (especially Vitamin C and Zinc), and minerals are essential for skin repair and regeneration. Nutritional deficiencies impair collagen synthesis and wound healing processes.
  • Dehydration: Insufficient fluid intake leads to decreased skin turgor and dryness, making the skin more fragile and prone to tears and breakdown.
• Immobility and Paralysis: Prolonged pressure on bony prominences due to immobility, whether from paralysis, bed rest, or physical limitations, restricts blood flow and leads to pressure injuries (bedsores).
• Sensory Perception Deficits: Conditions affecting sensory nerves can diminish the ability to perceive pain or pressure, increasing the risk of unnoticed injuries and prolonged pressure leading to skin breakdown.
• Hyperthermia and Hypothermia: Extreme body temperatures can negatively impact skin integrity. Hyperthermia (elevated body temperature) can lead to increased perspiration and skin maceration, while hypothermia (low body temperature) can cause vasoconstriction and impaired tissue perfusion.

External Factors:

• Pressure: Sustained pressure, particularly over bony prominences, compresses blood vessels, leading to ischemia, tissue damage, and pressure ulcers.
• Shearing and Friction: Shearing forces occur when skin and underlying tissues move in opposite directions, damaging blood vessels. Friction, the rubbing of skin against surfaces like bed linens, can erode the epidermis, making the skin more susceptible to breakdown.
• Moisture and Secretions: Excessive moisture from perspiration, incontinence (urine or stool), wound drainage, or other bodily fluids can macerate the skin, weakening its barrier function and increasing vulnerability to breakdown and infection.
• Chemical Irritants: Exposure to harsh chemicals, soaps, detergents, and certain topical medications can irritate and damage the skin, leading to dermatitis and impaired integrity.
• Radiation: Radiation therapy can cause radiation dermatitis, characterized by skin redness, dryness, peeling, and potential ulceration in the treated area.
• Surgical Incisions and Wounds: Surgical procedures and traumatic wounds inherently disrupt skin integrity, creating a portal of entry for pathogens if not properly managed.
• Medical Devices: Medical devices such as casts, braces, oxygen tubing, and catheters can exert pressure or friction on the skin, potentially causing pressure injuries or skin irritation.

Signs and Symptoms (Clinical Manifestations) of Impaired Skin Integrity

Recognizing the signs and symptoms of impaired skin integrity is crucial for early intervention and preventing further complications. These manifestations can be categorized as subjective (patient-reported) and objective (nurse-assessed) findings.

Subjective Symptoms (Patient Reports):

• Pain: Patients may report pain at the site of skin breakdown, ranging from mild discomfort to severe pain, depending on the extent of tissue damage and nerve involvement.
• Itching (Pruritus): Itching can be a symptom of skin irritation, dryness, or inflammation associated with impaired skin integrity.
• Numbness or Tingling (Paresthesia): Nerve damage or compression can lead to altered sensation, including numbness or tingling in the affected and surrounding skin areas.
• Increased Sensitivity: Conversely, some patients may experience heightened sensitivity to touch or pressure in areas of skin breakdown.

Objective Signs (Nurse Assesses):

• Changes in Skin Color:
  • Erythema (Redness): Redness indicates inflammation and increased blood flow to the area, often an early sign of pressure injury or skin irritation.
  • Bruising (Ecchymosis): Bruising suggests trauma to the skin and underlying tissues, potentially indicating shearing forces or injury.
  • Blanching: In normal skin, pressing on reddened skin will cause it to blanch (turn pale) and then return to red when pressure is released. Non-blanching erythema, particularly over bony prominences, is a key indicator of a Stage 1 pressure injury, suggesting impaired blood flow and potential tissue damage.
  • Pallor (Paleness): Paleness may indicate reduced blood flow or ischemia to the skin.
  • Cyanosis (Bluish Discoloration): Bluish skin discoloration suggests severe oxygen deprivation and potential tissue necrosis.
• Changes in Skin Temperature:
  • Warmth: Increased warmth to the skin may indicate inflammation or infection.
  • Coolness: Coolness may suggest impaired circulation and reduced blood flow.
• Swelling (Edema): Swelling in the tissues surrounding impaired skin integrity can be a sign of inflammation, infection, or fluid accumulation.
• Breaks in Skin Surface:
  • Observed Open Areas or Breakdown: This includes abrasions, lacerations, fissures, blisters, skin tears, and pressure ulcers of varying stages.
  • Excoriation: Superficial skin damage resulting from scratching or rubbing, often due to itching or irritation.
• Drainage: Wound drainage can vary in color, consistency, and odor, providing clues about the type of wound and potential infection. Types of drainage include serous (clear, watery), sanguineous (bloody), serosanguineous (mixture of serous and sanguineous), and purulent (thick, milky, often odorous, indicating infection).
• Odor: Foul odor emanating from a wound is a strong indicator of infection.
• Tissue Changes:
  • Maceration: Softening and breakdown of skin due to prolonged exposure to moisture, often appearing white or pale and wrinkled.
  • Induration: Hardening of the tissue surrounding a wound, which can indicate inflammation or cellulitis.

Expected Outcomes (Goals) for Impaired Skin Integrity

Establishing clear and measurable expected outcomes is essential for guiding the patient plan of care and evaluating its effectiveness. For patients with a nursing diagnosis of impaired skin integrity, common expected outcomes include:

• Maintenance of Intact Skin Integrity: The patient will maintain intact skin without new areas of breakdown or injury throughout their care. This is a primary goal for prevention.
• Timely Wound Healing without Complications: For patients with existing wounds, the goal is for them to experience timely and progressive wound healing without developing complications such as infection, delayed healing, or chronic wounds.
• Demonstration of Effective Wound Care Practices: Patients and/or their caregivers will be able to demonstrate proper wound care techniques, including dressing changes, wound cleansing, and pressure relief measures, as appropriate for their specific needs.
• Verbalization of Pressure Injury Prevention Strategies: Patients and/or their caregivers will verbalize understanding of risk factors for pressure injuries and demonstrate knowledge of preventative measures, such as repositioning, pressure-relieving devices, and skin hygiene.
• Reduced Pain and Discomfort: Patients will experience a reduction in pain and discomfort associated with impaired skin integrity.
• Prevention of Infection: Patients will remain free from infection related to impaired skin integrity.

Nursing Assessment for Impaired Skin Integrity

A comprehensive and systematic nursing assessment is the cornerstone of developing an effective patient plan of care. The assessment should encompass both subjective and objective data collection to identify risk factors, current skin status, and patient-specific needs.

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, and more frequently if indicated. This routine assessment allows for early detection of skin changes and potential breakdown. Pay particular attention to high-risk areas, including bony prominences (sacrum, coccyx, heels, elbows, hips, ischial tuberosities), skin folds, and areas under medical devices.

2. Utilize the Braden Scale for Pressure Injury Risk Assessment: The Braden Scale is an evidence-based tool widely used to assess a patient’s risk for developing pressure injuries. It evaluates six key parameters:

• Sensory Perception: Ability to respond meaningfully to pressure-related discomfort.
• Moisture: Degree to which skin is exposed to moisture.
• Activity: Degree of physical activity.
• Mobility: Ability to change and control body position.
• Nutrition: Usual food intake pattern.
• Friction and Shear: Assistance required to move in bed and chair, and degree of sliding.

Scoring: Scores range from 6 to 23, with lower scores indicating higher risk. Institutional policies dictate the frequency of Braden Scale assessments, but nurses should also utilize it whenever they suspect an increased risk of skin breakdown.

3. Assess Circulatory Status: Evaluate skin circulation, sensation, and turgor.

• Circulation: Assess skin color, temperature, and peripheral pulses. Diminished or absent pulses, cool skin temperature, and pallor or cyanosis suggest impaired circulation.
• Sensation: Evaluate the patient’s ability to perceive light touch, pain, and pressure, particularly in areas at risk for breakdown. Diminished sensation increases the risk of unnoticed injury.
• Skin Turgor: Gently pinch and release a fold of skin (e.g., on the forearm or sternum). Poor skin turgor (skin remaining tented) indicates dehydration, which increases the risk of skin breakdown.

4. Assess Activity Level and Mobility: Observe the patient’s ability to move and reposition themselves in bed and chair. Patients with limited mobility are at high risk for pressure injuries. Note if the patient:

• Is bedridden or chair-bound.
• Requires assistance with repositioning.
• Is able to shift weight independently.
• Uses restraints, which can increase pressure and friction.

5. Determine Risk of Skin Breakdown Related to Moisture: Assess the patient’s exposure to moisture from:

• Perspiration (Sweat): Note excessive sweating, which can occur with fever, hyperthermia, or certain medical conditions.
• Incontinence: Assess for urinary and/or fecal incontinence, which exposes skin to irritating moisture and enzymes.
• Wound Drainage: Evaluate the amount, type, and frequency of wound drainage.
• Other Secretions: Consider other potential sources of moisture, such as saliva, mucus, or emesis.

6. Evaluate Patient’s Ability for Self-Care: Assess the patient’s ability to perform hygiene and self-care activities related to skin integrity, including:

• Bathing and skin cleansing.
• Drying skin thoroughly.
• Managing incontinence.
• Applying barrier creams or protectants.
• Repositioning.

7. Describe Any Existing Wounds Thoroughly: Accurate documentation of existing wounds is crucial for monitoring healing progress and treatment effectiveness. For each wound, document:

• Location: Anatomical site.
• Type: Pressure ulcer stage, surgical incision, laceration, burn, etc.
• Size: Length, width, and depth (in centimeters or millimeters).
• Stage (for pressure ulcers): Use a validated staging system (e.g., National Pressure Ulcer Advisory Panel stages).
• Wound Bed: Describe the tissue type (e.g., granulation, slough, eschar).
• Periwound Skin: Assess the skin surrounding the wound for color, temperature, edema, and condition (e.g., macerated, excoriated).
• Drainage: Amount, color, consistency, and odor.
• Odor: Presence and characteristics of any wound odor.
• Tunneling or Undermining: Presence and extent of tissue damage extending beneath the wound edges.
• Pain: Patient’s pain level and characteristics.
• Photographic Documentation: Consider taking photographs of wounds for objective comparison over time, following institutional policy and with patient consent.

8. Assess Nutritional and Hydration Status: Evaluate the patient’s nutritional intake and hydration status, as these are critical for wound healing and skin integrity.

• Dietary History: Assess usual dietary intake, including protein, vitamins, and minerals.
• Fluid Intake: Evaluate daily fluid intake and signs of dehydration.
• Laboratory Values: Review relevant lab values such as serum albumin, prealbumin, and complete blood count (CBC).

9. Assess Stoma and Ostomy Sites (if applicable): For patients with ostomies, assess the stoma and peristomal skin:

• Stoma Viability: Stoma should be pink to red, moist, and protrude slightly. Note any signs of pallor, cyanosis, or necrosis.
• Peristomal Skin: Assess the skin surrounding the stoma for irritation, redness, breakdown, or infection.
• Ostomy Appliance Fit: Evaluate the fit and seal of the ostomy appliance to ensure it is properly protecting the peristomal skin.

Nursing Interventions for Impaired Skin Integrity

Nursing interventions are crucial for both preventing and treating impaired skin integrity. These interventions are aimed at addressing the underlying causes, promoting wound healing, and protecting the skin from further damage.

1. Implement Wound Care Protocols as Prescribed: Follow established wound care protocols based on the type, size, location, and stage of the wound, as well as physician orders and facility policies. This may include:

• Wound Cleansing: Using appropriate cleansing solutions (e.g., normal saline) and techniques to remove debris and exudate.
• Debridement: Removing nonviable tissue (slough, eschar) to promote wound healing (may be sharp, enzymatic, autolytic, mechanical, or biological debridement).
• Dressing Selection: Choosing appropriate wound dressings to maintain a moist wound environment, absorb exudate, protect the wound, and promote healing (e.g., hydrocolloids, hydrogels, foams, alginates, films).
• Topical Medications: Applying prescribed topical medications, such as antimicrobial ointments or growth factors, as indicated.

2. Position and Reposition the Patient Frequently: Regular repositioning is essential to relieve pressure on bony prominences and promote circulation.

• Repositioning Schedule: Establish a repositioning schedule (e.g., every 2 hours in bed, every hour in a chair), and document repositioning. Use a turn clock or reminder system as needed.
• Protect Bony Prominences: Use pillows, foam wedges, or pressure-redistributing devices to offload pressure from bony prominences such as heels, elbows, hips, knees, and sacrum.
• Lateral Rotation Therapy: Consider using specialized beds with lateral rotation features to automatically reposition patients and reduce pressure.

3. Ensure Adequate Skin Perfusion: Promote optimal blood flow to the skin and wound tissues.

• Avoid Positioning that Restricts Circulation: Avoid prolonged pressure on bony prominences and positions that compromise blood flow.
• Promote Activity and Mobility: Encourage patients to be as active as possible, within their limitations, to improve circulation.
• Maintain Hydration: Adequate hydration is essential for optimal blood volume and tissue perfusion.
• Manage Underlying Conditions: Optimize management of underlying conditions that impair circulation, such as diabetes and PVD.

4. Maintain Skin Hygiene and Manage Moisture: Keep the skin clean and dry to prevent maceration and irritation.

• Gentle Skin Cleansing: Cleanse skin regularly with mild, pH-balanced cleansers and warm water. Avoid harsh soaps or hot water.
• Thorough Drying: Pat skin dry gently after cleansing, paying particular attention to skin folds.
• Barrier Creams and Protectants: Apply barrier creams or ointments to protect skin from moisture and irritants, especially in patients with incontinence.
• Manage Incontinence: Implement strategies to manage incontinence promptly, such as frequent toileting, absorbent products, and containment devices.
• Control Perspiration: Keep the environment cool and dry, and use moisture-wicking linens and clothing to minimize perspiration.

5. Alleviate Pressure and Utilize Pressure-Relieving Devices: Reduce pressure on vulnerable skin areas.

• Pressure-Redistributing Mattresses and Overlays: Use pressure-redistributing mattresses, overlays, or cushions (e.g., low-air loss mattresses, foam overlays, gel cushions) to reduce pressure on bony prominences.
• Offloading Devices: Utilize offloading devices such as heel protectors (waffle boots), wedge pillows, and specialized cushions for chairs and beds to further reduce pressure on specific areas.
• Avoid Doughnut-Type Devices: Do not use doughnut-shaped cushions, as they can concentrate pressure around the area and impair circulation.

6. Promote Proper Nutrition and Hydration: Ensure adequate nutritional and fluid intake to support skin health and wound healing.

• Nutritional Assessment: Collaborate with a dietitian to assess nutritional status and identify any deficiencies.
• High-Protein Diet: Encourage a diet rich in protein, which is essential for tissue repair.
• Vitamins and Minerals: Ensure adequate intake of vitamins and minerals crucial for wound healing, such as Vitamin C, Zinc, and Vitamin A.
• Hydration: Encourage adequate fluid intake to maintain skin turgor and tissue perfusion.

7. Protect Skin from Further Injury: Prevent additional trauma to the skin.

• Protective Clothing and Footwear: Encourage patients to wear protective clothing and footwear (e.g., socks, non-slip shoes) to prevent skin injuries, especially for patients with sensory deficits or compromised neurovascular status.
• Smooth Bed Linens and Clothing: Use smooth, wrinkle-free bed linens and clothing to minimize friction.
• Careful Transfers and Repositioning: Use proper lifting and transfer techniques to avoid shearing and friction during patient movement.

8. Coordinate with Wound/Ostomy Specialists: Consult and collaborate with wound and ostomy care specialists for complex wounds or ostomy management. These specialists can provide expert recommendations on wound care protocols, dressing selection, ostomy appliance management, and patient education.

9. Minimize Skin Irritation: Reduce exposure to potential irritants.

• Avoid Harsh Chemicals and Soaps: Use mild, pH-balanced cleansers and avoid harsh chemicals, antibacterial soaps, and alcohol-based products.
• Barrier Pastes and Powders: Use barrier pastes and powders to protect skin around stomas or areas exposed to moisture and prevent irritation.
• Adhesive Removers: Use adhesive removers when changing dressings or ostomy appliances to minimize skin trauma and irritation.

10. Manage Ostomy Pouches Properly (if applicable): For patients with ostomies, ensure proper ostomy pouch management to protect peristomal skin.

• Proper Pouch Fitting: Ensure the ostomy wafer is correctly sized and fitted to the stoma to prevent leakage and skin irritation.
• Regular Pouch Emptying: Instruct patients to empty ostomy pouches when they are ⅓ to ½ full to prevent them from pulling away from the skin and causing leakage.
• Peristomal Skin Care Education: Educate patients on proper peristomal skin care, including cleansing, drying, and applying barrier products as needed.

Nursing Care Plans for Impaired Skin Integrity

Nursing care plans provide a structured framework for organizing assessments, interventions, and expected outcomes to address the nursing diagnosis of impaired skin integrity. Here are examples of care plans tailored to different etiologies 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 on the sacrum.

Expected Outcomes:

• Patient will demonstrate improvement of pressure ulcer stage from Stage 2 to improved healing within [specify timeframe, e.g., 2 weeks] of nursing interventions.
• Patient will maintain clean and dry skin throughout each shift.
• Patient will actively participate and cooperate with wound care procedures within [specify timeframe, e.g., 1 hour] of nursing intervention.
• Patient will verbalize understanding of at least three pressure ulcer prevention strategies within [specify timeframe, e.g., 1 hour] of nursing education.

Assessments:

1. Regular Skin and Wound Assessment: Assess skin integrity, particularly over bony prominences, at least once per shift. Monitor pressure ulcer site for signs of worsening (increased redness, drainage, size). Measure wound dimensions (length, width, depth) weekly to track progress.
2. Mobility Assessment: Determine the patient’s level of mobility and need for assistance with repositioning. Assess ability to independently shift weight.
3. Need for Positioning Devices: Evaluate the need for pressure-relieving devices (pillows, wedges, specialized mattresses) based on patient’s mobility, body size, and risk factors.

Interventions:

1. Wound Care as Ordered: Perform wound care to sacral pressure ulcer according to physician orders and wound care protocols. This may include cleansing, debridement, and application of appropriate dressings.
2. Repositioning and Pressure Relief: Implement a repositioning schedule (e.g., turn every 2 hours). Support bony prominences (sacrum, heels, hips) with pillows or pressure-relieving devices during repositioning.
3. Maintain Clean and Dry Skin: Assess for incontinence and perspiration. Cleanse skin gently and pat dry after episodes of incontinence or perspiration. Keep bed linens and clothing clean, dry, and wrinkle-free.
4. Utilize Pressure-Redistributing Devices: Apply pressure-redistributing mattress overlay or low-air loss mattress as indicated. Utilize wedge pillows and heel protectors to offload pressure.
5. Promote Nutrition and Hydration: Encourage adequate oral intake of fluids and a high-protein diet. Consult dietitian for nutritional assessment and recommendations as needed.

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 open area on the left lower leg.

Expected Outcomes:

• Patient will exhibit intact skin on lower extremities without signs of new breakdown at the end of each shift.
• Patient will verbalize at least two methods to prevent skin infection in lower extremities within [specify timeframe, e.g., 1 hour] of nursing education.
• Patient will maintain adequate skin perfusion as evidenced by controlled blood glucose levels within target range by the end of each shift.
• Patient will demonstrate understanding of daily foot and skin inspection by verbalizing key inspection points within [specify timeframe, e.g., 1 hour] of teaching.

Assessments:

1. Assess Skin for Infection: Monitor lower leg wound and surrounding skin for signs of infection: redness, purulent drainage, warmth, odor, swelling.
2. Assess Skin Perfusion: Evaluate skin color, temperature, and capillary refill in lower extremities. Assess peripheral pulses.
3. Monitor Blood Glucose Levels: Regularly monitor blood glucose levels to assess glycemic control, which impacts wound healing and infection risk in diabetic patients.

Interventions:

1. Blood Glucose Management: Administer insulin or oral hypoglycemic agents as prescribed to maintain blood glucose levels within target range. Monitor blood glucose levels regularly.
2. Educate on Diabetic Neuropathy and Skin Checks: Educate patient about diabetic neuropathy, decreased sensation in feet and legs, and the importance of daily self-inspection of feet and lower legs for any injuries, redness, or breaks in skin.
3. Ensure Foot Protection: Instruct patient to wear protective footwear at all times, even indoors. Avoid walking barefoot. Recommend well-fitting shoes and socks. Inspect shoes daily for any foreign objects or rough seams.

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 at least two strategies to prevent skin irritation around the stoma within [specify timeframe, e.g., 1 hour] of nursing education.
• Patient will exhibit a moist and pinkish stoma without signs of necrosis or excessive edema at the end of each shift.
• Patient will enumerate at least two ways to protect the stoma from skin breakdown within [specify timeframe, e.g., 1 hour] of teaching.
• Patient will demonstrate proper technique for fitting and emptying ostomy pouch within [specify timeframe, e.g., 1 hour] of instruction.

Assessments:

1. Determine Indication for Surgery/Stoma: Understand the underlying medical condition necessitating stoma creation to inform holistic care planning.
2. Assess Incision and Stoma: Assess surgical incision site for signs of infection (redness, drainage, swelling). Evaluate stoma appearance: color (pink-red, moist), protrusion, edema, and any signs of complications.
3. Determine Dietary Intake: Assess patient’s nutritional status and dietary intake, as nutrition plays a role in wound healing and ostomy output management.

Interventions:

1. Collaborate with Wound/Ostomy Specialist: Consult with a wound and ostomy care nurse specialist for ongoing assessment, management, and education related to the stoma and peristomal skin care.
2. Develop Meal Plans: Collaborate with dietitian and patient to develop meal plans that promote bowel healing and manage ostomy output. Educate patient on dietary modifications (e.g., low-residue diet initially) and foods to avoid that may cause diarrhea or excessive gas.
3. Minimize Peristomal Skin Irritation: Educate patient on proper peristomal skin care, including gentle cleansing with water, patting skin dry, and applying barrier pastes or powders as needed to protect skin from stoma output.
4. Educate on Ostomy Pouch Management: Provide comprehensive education on proper ostomy pouch application, wafer sizing, pouch emptying frequency (⅓ to ½ full), and techniques to ensure a secure seal and prevent leakage.

Care Plan #4: Impaired Skin Integrity Related to Burn Wounds

Diagnostic Statement: Impaired skin integrity related to burn wounds on the [specify body area].

Expected Outcomes:

• Patient will demonstrate skin restoration with evidence of tissue regeneration within [specify timeframe, e.g., 6 months].
• Patient will maintain intact wound dressings without signs of contamination at the end of each shift.
• Patient will demonstrate cooperation and compliance with burn wound care regimen at the end of each shift.
• Patient will verbalize at least two strategies to prevent skin infection in burn wounds within [specify timeframe, e.g., 1 hour] of nursing education.

Assessments:

1. Assess Burn Wound Severity: Determine the depth and extent of burn wounds to guide treatment and assess infection risk.
2. Determine Burn Degree: Classify burns according to degree (first, second, third, fourth) to guide treatment and prognosis.
3. Assess Patient Knowledge of Wound Dressing: Evaluate patient’s understanding of burn wound care and dressing changes to identify knowledge gaps and tailor education.

Interventions:

1. Apply Wound Dressings: Apply sterile wound dressings to burn areas according to burn protocols and physician orders. Maintain aseptic technique during dressing changes to minimize infection risk.
2. Wound Cleansing and Debridement: Cleanse burn wounds regularly as prescribed. Assist with or perform wound debridement (surgical, hydrosurgical, enzymatic, mechanical, biological) to remove nonviable tissue and promote healing.
3. Promote New Skin Growth: Implement strategies to promote skin regeneration, which may include specialized dressings, skin grafts, or tissue engineering approaches as indicated.
4. Encourage Patient Compliance with Wound Care: Provide adequate pain management prior to dressing changes. Educate patient about the importance of adhering to the wound care regimen to promote healing and prevent infection. Address any anxiety or fear related to 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 at least two interventions to prevent further skin irritation in the radiation treatment area.
• Patient will promptly report any signs of worsening skin breakdown (peeling, open areas, drainage) to the nurse or healthcare provider.

Assessments:

1. Assess Skin Prior to Each Treatment: Assess skin integrity in the radiation treatment area before each radiation therapy session to monitor for changes and early signs of breakdown or infection.
2. Assess Patient Understanding of Skin Reactions: Evaluate patient’s understanding of expected skin reactions to radiation therapy (e.g., redness, dryness) versus abnormal reactions (blisters, rash, open areas) that require medical attention.

Interventions:

1. Moisturize After Treatments: Instruct patient to apply a non-irritating, fragrance-free, lanolin-free moisturizer to the treated area after each radiation session to keep skin hydrated and minimize dryness. Avoid applying lotions immediately before treatment.
2. Keep Skin Clean and Dry: Advise patient to cleanse the treated area gently with warm water and mild soap. Pat skin dry and avoid rubbing.
3. Avoid Abrasive Cleaners: Instruct patient to avoid using antibacterial soaps, alcohol-based products, washcloths, or loofahs on the treated skin, as these can cause further irritation.
4. Wear Loose Clothing and Comfortable Bra: Recommend loose-fitting, breathable cotton clothing to minimize friction. Advise women to wear a soft, non-underwire bra if needed.
5. Avoid Direct Sun Exposure: Educate patient to protect the treated skin from direct sun exposure by covering it with loose clothing or using non-irritating sunscreen as advised by their healthcare provider, as radiation-treated skin is highly sensitive to UV rays.