Skin Care Nursing Diagnosis: A Comprehensive Guide for Nurses

The skin, our body’s largest organ, acts as the primary defense against the external environment. It’s a crucial barrier, protecting us from pathogens and maintaining internal homeostasis. However, when this barrier is compromised due to various factors like injuries, medical conditions, or treatments, it leads to impaired skin integrity, a significant concern in healthcare. Understanding Skin Care Nursing Diagnosis is paramount for nurses to effectively assess, prevent, and manage skin-related issues, ultimately promoting patient well-being and recovery.

In this comprehensive guide, we will delve into the intricacies of skin care nursing diagnosis, exploring its causes, symptoms, assessment techniques, and evidence-based interventions. This resource aims to equip nurses with the knowledge and tools necessary to provide exceptional skin care and achieve positive patient outcomes.

Understanding Impaired Skin Integrity: Causes and Risk Factors

Impaired skin integrity occurs when the normal protective function of the skin is disrupted. This can range from minor superficial breaks to deep tissue damage, increasing the risk of infection and complications. Identifying the underlying causes is the first step in formulating an effective skin care nursing diagnosis and subsequent care plan. These causes can be broadly categorized into internal and external factors:

Internal Factors:

These factors originate within the body and can predispose individuals to skin integrity issues:

• Hyperthermia: Elevated body temperature can lead to excessive sweating and moisture, weakening the skin and making it more susceptible to breakdown.
• Hypothermia: Conversely, low body temperature can reduce blood flow to the skin, impairing cellular function and healing.
• Extremes in Age: Both very young and elderly individuals have more fragile skin. Infants have thinner, less developed skin, while older adults experience age-related skin changes like reduced elasticity and moisture.
• Cognitive Impairment: Patients with cognitive deficits may be unable to recognize or communicate discomfort or skin issues, leading to delayed intervention.
• Chronic Diseases: Conditions like diabetes, peripheral vascular disease, and malnutrition compromise circulation and tissue health, increasing vulnerability to skin breakdown.
• Immobility: Prolonged pressure on bony prominences due to immobility significantly reduces blood flow, leading to pressure injuries (bedsores).
• Paralysis: Loss of motor function results in immobility and loss of sensation, increasing the risk of pressure damage.
• Surgery: Surgical incisions disrupt skin integrity and create entry points for infection.
• Wounds: Existing wounds, whether surgical or traumatic, compromise the surrounding skin and require diligent care.

External Factors:

These factors originate from the environment and directly impact the skin:

• Radiation: Radiation therapy, while targeting cancer cells, can also damage healthy skin cells, causing radiation dermatitis.
• Chemicals: Exposure to harsh chemicals, irritants, and allergens can cause contact dermatitis and skin damage.
• Moisture/Secretions: Excessive moisture from sweat, urine, stool, or wound drainage macerates the skin, making it fragile and prone to breakdown.
• Shearing/Friction/Pressure: These mechanical forces, often occurring during patient repositioning or movement in bed, can damage the skin, especially over bony prominences.

Understanding these multifaceted causes is crucial for nurses in making accurate skin care nursing diagnoses and implementing preventative measures.

Recognizing Signs and Symptoms of Impaired Skin Integrity

Identifying the signs and symptoms of impaired skin integrity is a cornerstone of effective skin care nursing diagnosis. These manifestations can be subjective, reported by the patient, or objective, observed and assessed by the nurse.

Subjective Symptoms (Patient Reports):

These are what the patient verbally communicates about their skin condition:

• Pain: Pain can range from mild discomfort to severe, depending on the extent of skin damage and underlying cause.
• Itching: Pruritus or itching is a common symptom associated with skin irritation, dryness, or allergic reactions.
• Numbness: Numbness or altered sensation can indicate nerve damage or circulatory issues affecting the skin.

Objective Signs (Nurse Assesses):

These are observable and measurable indicators of impaired skin integrity:

• Changes to Skin Color:
  • Erythema: Redness of the skin, often indicating inflammation or pressure.
  • Bruising: Ecchymosis or bruising suggests trauma or underlying tissue injury.
  • Blanching: Pale or white skin upon pressure, which may indicate impaired circulation and risk of pressure injury. Non-blanchable erythema is a key sign of a pressure injury.
• Warmth to Skin: Increased skin temperature can be a sign of inflammation or infection.
• Swelling to Tissues: Edema or swelling can indicate fluid accumulation due to injury, inflammation, or circulatory problems.
• Observed Open Areas or Breakdown, Excoriation: Visible breaks in the skin, ranging from superficial abrasions to deep ulcers, are direct signs of impaired skin integrity. Excoriation refers to superficial skin damage, often caused by scratching.

Image: Example of a Stage 2 pressure ulcer, a clear manifestation of impaired skin integrity.

Recognizing both subjective and objective signs is vital for a thorough skin care nursing diagnosis, guiding appropriate interventions to prevent further deterioration and promote healing.

Nursing Assessment: The Foundation of Skin Care Diagnosis

A comprehensive nursing assessment is the bedrock of accurate skin care nursing diagnosis. It involves systematic data collection to identify existing skin integrity issues, assess risk factors, and guide the development of individualized care plans. This assessment includes both subjective and objective data gathering, utilizing various tools and techniques.

1. Conduct a Thorough Skin Assessment:

A head-to-toe skin examination should be performed upon admission, during unit transfers, and regularly (at least once per shift, or more frequently as needed). This proactive approach allows for early detection and prevention of skin breakdown. Particular attention should be paid to high-risk areas, such as bony prominences (sacrum, 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 of developing pressure injuries. It evaluates six key criteria:

• Sensory Perception: Ability to feel and respond to discomfort or pressure.
• Moisture: Degree of skin exposure to moisture.
• 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 friction and shear forces.

Each criterion is scored, and the total score ranges from 6 to 23. A lower score indicates a higher risk of pressure injury development. Regular Braden Scale assessments, as per institutional policy and nursing judgment, are essential for identifying at-risk patients and implementing preventive strategies.

3. Assess Circulatory Status:

Evaluating circulatory status is critical as adequate blood flow is essential for skin health and wound healing. Assess:

• Skin Turgor: Assesses hydration status and skin elasticity. Poor turgor (skin that remains tented after pinching) can indicate dehydration and increased risk of skin breakdown.
• Sensation: Assess the patient’s ability to feel light touch and pressure, particularly in extremities. Diminished sensation (neuropathy) increases the risk of injury as patients may not be aware of pressure or trauma.
• Circulation: Observe skin color and temperature. Cool, pale, or bluish skin, especially in the lower legs and feet, may indicate poor arterial circulation. Palpate peripheral pulses to assess blood flow. Reddish or purple discoloration in dependent areas may suggest venous insufficiency.

4. Assess Activity Level and Mobility:

Patient’s ability to move and reposition themselves significantly impacts skin integrity. Assess:

• Ability to Ambulate: Can the patient walk independently, with assistance, or are they bedridden?
• Mobility in Bed/Chair: Can the patient independently reposition themselves in bed or chair to relieve pressure?
• Restraints: Patients using physical restraints are at increased risk of skin breakdown due to restricted movement and potential for friction.

5. Determine Risk of Skin Breakdown Related to Moisture:

Moisture, especially prolonged exposure, is a major risk factor for skin damage. Assess:

• Perspiration: Excessive sweating (diaphoresis) can contribute to skin maceration.
• Incontinence: Incontinence of urine or stool exposes the skin to irritating substances and prolonged moisture, significantly increasing breakdown risk.
• Wound Drainage/Body Secretions: Assess the type, amount, and frequency of wound drainage, ostomy output, or other body secretions that may contact the skin.

6. Evaluate Patient’s Ability for Self-Care:

Patient’s capacity for self-care directly influences their ability to maintain skin integrity. Assess:

• Incontinence Management: Can the patient manage incontinence independently, or do they require assistance?
• Hygiene Practices: Does the patient have the ability and resources to maintain personal hygiene, including skin cleaning and drying?
• Communication of Needs: Can the patient effectively communicate their needs for assistance with skin care or repositioning?

7. Describe and Document Any Wounds:

Accurate and detailed wound documentation is crucial for monitoring healing progress and treatment effectiveness. For any observed wounds or skin breakdown:

• Location: Precisely describe the anatomical location of the wound.
• Size: Measure length, width, and depth in centimeters.
• Stage (for Pressure Ulcers): Stage pressure ulcers according to established staging systems (Stage 1 to Stage 4, Unstageable, Deep Tissue Pressure Injury).
• Wound Bed: Describe the tissue type in the wound bed (e.g., granulation tissue, slough, eschar).
• Periwound Area: Describe the skin surrounding the wound (e.g., erythema, edema, maceration).
• Drainage: Note the type (serous, serosanguineous, sanguineous, purulent), amount (scant, small, moderate, large), color, and odor of any drainage.
• Tunneling or Undermining: Assess for and document any tunneling (channels extending from the wound edge) or undermining (tissue destruction under intact skin at the wound edge).
• Photographic Documentation: Consider taking photographs of wounds for baseline and comparative assessment, following institutional policies and obtaining patient consent.

8. Assess Nutritional and Hydration Status:

Nutrition and hydration are vital for tissue repair and wound healing. Assess:

• Dietary Intake: Evaluate the patient’s usual dietary intake, including protein, vitamins, and minerals essential for skin health.
• Fluid Intake: Assess hydration status and fluid intake, as adequate hydration supports tissue perfusion and wound healing.
• Laboratory Values: Review relevant lab values, such as serum albumin and prealbumin levels, which can indicate nutritional status.

9. Assess Stoma and Ostomy Sites (if applicable):

For patients with ostomies, specialized assessment is required:

• Stoma Appearance: Assess stoma color (should be pink to red and moist), size, and protrusion.
• Peristomal Skin: Examine the skin surrounding the stoma for irritation, redness, breakdown, or signs of infection.
• Ostomy Appliance Fit: Evaluate the fit and security of the ostomy appliance.

By systematically conducting these comprehensive assessments, nurses gather the essential data for formulating accurate skin care nursing diagnoses and developing tailored care plans to address individual patient needs.

Developing a Skin Care Nursing Diagnosis Statement

The nursing assessment data forms the basis for formulating a skin care nursing diagnosis. This diagnostic statement concisely identifies the patient’s skin integrity problem, its contributing factors (related to – etiology), and the evidence supporting the diagnosis (as evidenced by – signs and symptoms). A well-formulated skin care nursing diagnosis is crucial for guiding individualized care planning and interventions.

Components of a Nursing Diagnosis Statement:

• Problem: Clearly state the nursing diagnosis, such as “Impaired Skin Integrity” or “Risk for Impaired Skin Integrity.”
• Etiology (Related To): Identify the contributing factors or causes of the skin integrity problem. This links the diagnosis to the underlying issue, guiding targeted interventions. Examples include “related to immobility,” “related to moisture,” “related to decreased sensation secondary to diabetic neuropathy.”
• Signs and Symptoms (As Evidenced By): List the specific assessment findings that support the diagnosis. These are the subjective and objective data collected during the nursing assessment. Examples include “as evidenced by stage 2 pressure ulcer to the sacrum,” “as evidenced by redness and open area to the left lower leg,” “as evidenced by erythema and reports of irritation to the axillary area.”

Examples of Skin Care Nursing Diagnosis Statements:

• Impaired Skin Integrity related to immobility as evidenced by stage 2 pressure ulcer to the sacrum. (This diagnosis indicates an existing skin integrity problem due to immobility, evidenced by a pressure ulcer.)
• Risk for Impaired Skin Integrity related to incontinence and immobility. (This diagnosis indicates a potential problem due to risk factors, but no current skin breakdown is stated.)
• Impaired Skin Integrity related to surgical incision and stoma creation to the abdomen. (This diagnosis identifies skin disruption due to a surgical procedure.)
• Impaired Skin Integrity related to radiation therapy as evidenced by erythema and reports of irritation to the axillary area. (This diagnosis links skin irritation to radiation treatment.)
• Risk for Infection related to impaired skin integrity. (While not directly focused on skin integrity impairment itself, this is a related diagnosis that recognizes the increased risk of infection when skin is compromised.)
• Deficient Knowledge related to skin care management as evidenced by patient’s verbalization of lack of understanding regarding proper wound care techniques. (This diagnosis addresses a knowledge deficit impacting skin care management.)

Formulating accurate and specific skin care nursing diagnoses is essential for effective communication among healthcare team members, setting realistic patient outcomes, and planning appropriate nursing interventions.

Nursing Interventions and Skin Care Management Strategies

Nursing interventions are crucial for preventing and treating impaired skin integrity. Based on the skin care nursing diagnosis, nurses implement a range of evidence-based strategies to promote skin health, prevent further breakdown, and facilitate healing. These interventions are tailored to the individual patient’s needs and risk factors.

1. Implement Wound Care Protocols as Prescribed:

For existing wounds, follow established wound care protocols based on wound type, location, size, and depth. Wound care protocols may be prescribed by a wound care specialist or based on facility policies and procedures. This may include:

• Wound Cleansing: Using appropriate cleansing solutions (e.g., saline, prescribed cleansers) to remove debris and exudate.
• Debridement: Removing nonviable tissue (slough, eschar) to promote healing. Debridement methods may include sharp, enzymatic, mechanical, autolytic, or biologic, depending on the wound and clinical context.
• Dressing Selection: Applying appropriate dressings to maintain a moist wound environment, protect the wound, absorb exudate, and promote healing. Dressing choices vary based on wound characteristics (e.g., hydrogels, hydrocolloids, foams, alginates, films).
• Infection Control: Monitoring for signs of infection and implementing infection control measures, such as sterile technique during dressing changes and antibiotic therapy if indicated.

2. Position Patient Comfortably and Reposition Regularly:

Pressure relief is paramount in preventing and managing pressure injuries.

• Repositioning Schedule: For patients at risk or with impaired mobility, implement a regular repositioning schedule (e.g., every 2 hours, or more frequently as needed). Use a turn clock as a visual reminder.
• Protect Bony Prominences: Use pillows, foam wedges, or specialized positioning devices to offload pressure from bony prominences (heels, elbows, sacrum, hips, knees).
• Avoid Direct Pressure: Prevent prolonged direct pressure on vulnerable areas. Encourage patients who are able to shift their weight frequently.

3. Ensure Adequate Skin Perfusion:

Promoting circulation is essential for tissue health and wound healing.

• Positioning: Elevate extremities when appropriate to promote venous return. Avoid positions that restrict blood flow.
• Support Devices: Utilize cushions, pillows, and pressure-redistributing devices to minimize pressure and enhance perfusion to at-risk areas.

4. Maintain Skin Hygiene and Manage Moisture:

Keeping skin clean and dry is crucial for preventing maceration and irritation.

• Gentle Cleansing: Cleanse skin regularly with mild, pH-balanced cleansers and warm water. Avoid harsh soaps or excessive scrubbing.
• Thorough Drying: Pat skin dry gently after cleansing, paying particular attention to skin folds and areas prone to moisture accumulation.
• Moisture Barriers: Apply moisture barrier creams or ointments to protect skin from excessive moisture, especially in incontinent patients.
• Promptly Address Incontinence: Implement strategies to manage incontinence, such as frequent toileting, absorbent products, and barrier protection. Change soiled linens and garments promptly.

5. Alleviate Pressure with Specialized Equipment:

Utilize pressure-redistributing equipment to minimize pressure on vulnerable areas.

• Low-Air Loss Mattresses: These mattresses cycle air to redistribute pressure and reduce friction.
• Air Mattresses and Overlays: Air-filled mattresses and overlays provide pressure redistribution.
• Wedge Pillows: Used for positioning and pressure relief, particularly for bony prominences.
• Waffle Boots/Heel Protectors: Specialized boots or heel protectors to offload pressure from heels.
• Gel Overlays: Gel-filled pads for chairs and beds to redistribute pressure.

6. Promote Proper Nutrition and Hydration:

Adequate nutrition and hydration are fundamental for skin health and wound healing.

• Nutritional Assessment: Collaborate with a dietitian to assess and address any nutritional deficiencies.
• Protein Intake: Ensure adequate protein intake, as protein is essential for tissue repair and regeneration.
• Hydration: Encourage sufficient fluid intake to maintain skin hydration and tissue perfusion.
• Vitamin and Mineral Supplementation: Consider vitamin and mineral supplementation, as prescribed, to support wound healing (e.g., Vitamin C, Zinc).

7. Protect Skin from Further Injury:

Preventing further trauma is crucial for promoting healing.

• Protective Clothing/Footwear: Encourage patients to wear protective clothing, socks, and non-slip shoes to prevent skin injuries, especially for patients with compromised sensation (e.g., diabetic neuropathy).
• Minimize Friction and Shear: Use proper lifting and transfer techniques to minimize friction and shear forces during patient movement.
• Avoid Irritants: Minimize exposure to potential skin irritants, such as harsh chemicals, fragrances, and allergens.

8. Coordinate with Wound/Ostomy Specialist:

Consult with a wound/ostomy specialist for complex wounds, ostomy care, or when specialized expertise is needed. They can provide recommendations for:

• Wound Care Protocols: Guidance on advanced wound care techniques and dressing selections.
• Ostomy Management: Education and support for ostomy care, appliance selection, and peristomal skin management.

9. Manage Irritation and Peristomal Skin Care:

For patients with ostomies or skin irritation, specific interventions are needed.

• Barrier Pastes and Powders: Apply barrier pastes or powders around stomas or irritated areas to protect skin from moisture and irritants.
• Adhesive Removers: Use adhesive removers to gently remove ostomy appliances or dressings without causing skin trauma.
• Proper Ostomy Pouch Fitting: Ensure proper sizing and fitting of ostomy appliances to prevent leakage and peristomal skin irritation.
• Patient Education on Ostomy Care: Educate patients on proper ostomy pouch application, emptying, and skin care techniques.

By implementing these comprehensive nursing interventions, guided by a thorough skin care nursing diagnosis, nurses play a pivotal role in preventing, managing, and promoting healing of impaired skin integrity, ultimately improving patient comfort and outcomes.

Skin Care Nursing Care Plan Examples

Nursing care plans provide a structured framework for organizing and delivering patient care. For skin care nursing diagnosis, care plans outline specific goals, interventions, and evaluation criteria tailored to the individual patient’s needs. Here are examples of nursing care plans for different scenarios 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 stage 1 within 2 weeks of nursing interventions.
• Patient will demonstrate understanding of pressure ulcer prevention strategies by verbalizing two preventative measures by discharge.
• Patient will maintain intact skin integrity in other areas at risk for breakdown throughout hospitalization.
• Patient will report reduced pain at the pressure ulcer site within 24 hours of implementing pain management interventions.

Assessment:

1. Assess the skin and wounds regularly: Monitor skin at risk for breakdown at least once per shift, focusing on bony prominences. Assess pressure ulcer at sacrum daily, noting size, stage, wound bed characteristics, periwound skin, and drainage.
2. Determine patient’s mobility: Assess patient’s ability to reposition self in bed and chair. Evaluate need for assistance with turning and transfers.
3. Assess patient’s need for positioning devices: Determine need for pressure-redistributing mattress, pillows, wedges, and heel protectors based on risk assessment and mobility level.
4. Assess pain level related to pressure ulcer: Use pain scale to quantify pain and assess pain characteristics.

Interventions:

1. Perform wound care per guidelines and orders: Cleanse pressure ulcer with prescribed solution. Apply appropriate dressing (e.g., hydrocolloid, foam) as ordered.
2. Repositioning and support of bony prominences: Implement turning schedule (every 2 hours). Utilize pillows and wedges to support bony prominences (sacrum, hips, heels, elbows) and offload pressure.
3. Keep the skin clean and dry: Provide perineal care and skin cleansing after episodes of incontinence or perspiration. Apply moisture barrier cream to sacral area. Ensure bed linens are dry and wrinkle-free.
4. Use appropriate pressure-redistributing devices: Implement use of low-air loss mattress. Apply waffle boots to heels while in bed. Use gel cushion when patient is in chair.
5. Encourage nutrition and hydration: Consult dietitian for nutritional assessment and recommendations. Encourage high-protein diet and adequate fluid intake.
6. Pain Management: Administer pain medication as ordered. Assess pain relief effectiveness. Consider non-pharmacological pain management techniques (e.g., positioning, distraction).
7. Patient Education: Educate patient and family on pressure ulcer prevention strategies, including repositioning, skin inspection, and proper nutrition.

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 demonstrate intact skin on lower extremities without new areas of breakdown by discharge.
• Patient will verbalize understanding of daily foot and skin inspection and protective foot care measures by discharge.
• Patient will maintain skin perfusion by keeping blood glucose within target range as per physician orders.
• Patient will demonstrate proper foot care practices during hospitalization (e.g., wearing appropriate footwear, avoiding foot trauma).

Assessment:

1. Assess skin for infection: Monitor open area on left lower leg for signs of infection (redness, warmth, purulent drainage, odor, swelling). Assess for systemic signs of infection (fever, increased WBC count).
2. Determine skin perfusion: Assess peripheral pulses, skin temperature, and capillary refill in lower extremities.
3. Monitor patient’s blood glucose: Check blood glucose levels regularly and monitor trends. Assess patient’s understanding of diabetes management and blood glucose control.
4. Assess patient’s knowledge of diabetic foot care: Evaluate patient’s understanding of diabetic neuropathy, foot care practices, and importance of daily skin checks.

Interventions:

1. Control blood glucose: Administer insulin or oral hypoglycemic agents as ordered to maintain blood glucose within target range. Educate patient on importance of blood glucose control for wound healing and preventing complications.
2. Educate on diabetic neuropathy and importance of daily skin checks: Teach patient about diabetic neuropathy and its impact on sensation. Instruct on daily foot and skin inspection, emphasizing areas prone to pressure and injury. Provide written materials on diabetic foot care.
3. Ensure foot protection at all times: Advise patient to wear socks and supportive shoes or slippers at all times, even indoors. Avoid walking barefoot. Inspect shoes daily for foreign objects or rough linings.
4. Wound Care: Cleanse open area on lower leg as ordered. Apply appropriate dressing to promote healing and prevent infection. Elevate leg when possible to reduce edema and promote circulation.
5. Referral to Podiatry: Consult podiatrist for evaluation and management of foot wound and for ongoing diabetic foot care recommendations.
6. Patient Education on Foot Care Practices: Educate patient on proper foot hygiene (washing and drying feet daily), nail care (trimming toenails straight across), avoiding extreme temperatures, and seeking prompt medical attention for any foot problems.

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 peristomal skin care and ostomy pouch management by discharge.
• Patient will demonstrate a moist and pinkish stoma without signs of ischemia or necrosis throughout hospitalization.
• Patient will maintain intact peristomal skin without irritation or breakdown throughout hospitalization.
• Patient will demonstrate proper ostomy pouch application and emptying technique prior to discharge.

Assessment:

1. Determine indication for surgery or stoma: Review patient’s medical history and surgical procedure to understand the underlying condition and type of stoma created.
2. Assess incision and stoma: Inspect surgical incision for signs of infection (redness, drainage, warmth). Assess stoma color, size, protrusion, and moisture. Monitor for signs of stoma complications (ischemia, necrosis, retraction).
3. Determine patient’s diet: Assess patient’s dietary intake and tolerance to oral intake post-surgery. Consult dietitian for dietary recommendations to manage ostomy output and promote healing.
4. Assess patient’s knowledge and ability for ostomy self-care: Evaluate patient’s understanding of ostomy care and their physical and cognitive ability to learn and perform self-care.

Interventions:

1. Collaborate with a wound/ostomy specialist: Request consultation with a wound/ostomy specialist for stoma assessment, pouching system selection, and patient education.
2. Create meal plans with the patient: Educate patient on dietary modifications to manage ostomy output (e.g., low-residue diet initially, avoiding gas-producing foods). Provide dietary guidelines and sample meal plans.
3. Minimize skin irritation: Ensure proper fit of ostomy pouching system to prevent leakage onto peristomal skin. Use skin barrier wafers and pastes to protect peristomal skin. Teach patient to use adhesive remover to minimize skin trauma during pouch changes.
4. Educate the patient on properly fitting and emptying the ostomy pouch: Provide step-by-step instruction and demonstration on ostomy pouch application, emptying, and disposal. Provide hands-on practice and return demonstration. Offer written and visual educational materials.
5. Peristomal Skin Care: Cleanse peristomal skin gently with warm water and mild soap during pouch changes. Ensure skin is completely dry before applying new pouch. Monitor peristomal skin for irritation and implement appropriate skin care measures as needed (e.g., barrier creams, powders).
6. Stoma Assessment and Monitoring: Assess stoma appearance daily. Report any signs of stoma complications (changes in color, swelling, bleeding) to physician and wound/ostomy specialist.

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 as evidenced by tissue regeneration and wound closure within expected timeframe based on burn severity.
• Patient will maintain intact wound dressings without signs of infection throughout hospitalization.
• Patient will verbalize understanding of burn wound care and infection prevention measures by discharge.
• Patient will report manageable pain levels during wound care procedures and throughout recovery.

Assessment:

1. Assess the severity of the burn wound: Determine the extent of burn injury using the Rule of Nines or Lund-Browder chart. Document percentage of total body surface area (%TBSA) burned.
2. Determine the degree of burn: Classify burn depth as first-degree (superficial), second-degree (partial-thickness), third-degree (full-thickness), or fourth-degree (subdermal). Document characteristics of each burn area.
3. Assess patient’s knowledge about wound dressing: Evaluate patient’s understanding of burn wound care, dressing changes, and pain management expectations. Assess patient’s coping mechanisms and support systems.
4. Pain Assessment: Assess burn pain using pain scale and pain characteristics. Evaluate effectiveness of pain management strategies.

Interventions:

1. Apply wound dressing: Apply prescribed burn wound dressings using aseptic technique. Follow burn center protocols for dressing type and frequency of changes. May include topical antimicrobial agents, biologic dressings, or skin substitutes.
2. Cleanse the wound regularly: Cleanse burn wounds during dressing changes using prescribed cleansing solutions and techniques (e.g., hydrotherapy, gentle irrigation). Perform wound debridement as indicated to remove nonviable tissue.
3. Promote new skin growth: Ensure adequate nutrition and hydration to support tissue regeneration. Collaborate with burn team regarding potential skin grafting or other surgical interventions to promote wound closure.
4. Encourage patient compliance in wound dressing: Provide adequate pain management prior to and during dressing changes. Educate patient on importance of wound care compliance for healing and infection prevention. Address patient’s anxieties and concerns about wound care.
5. Pain Management: Administer pain medications as ordered, including analgesics and adjunctive pain medications. Utilize non-pharmacological pain management techniques (e.g., relaxation, imagery, distraction).
6. Infection Prevention: Monitor for signs of burn wound infection (increased drainage, purulent drainage, odor, fever). Implement strict infection control measures. Administer prophylactic antibiotics as ordered.
7. Patient Education: Educate patient and family on burn wound care, infection prevention, pain management, and rehabilitation. Provide resources and support for long-term burn recovery.

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 during radiation therapy by next radiation treatment session.
• Patient will alert nurse or radiation therapist to signs of worsening skin breakdown (peeling, open areas, drainage) immediately.
• Patient will maintain skin integrity in radiation treatment area without developing open areas or infection throughout radiation therapy course.
• Patient will report reduced skin irritation and discomfort in radiation treatment area within 48 hours of implementing skin care interventions.

Assessment:

1. Assess the skin prior to treatments: Inspect skin in radiation treatment area before each radiation therapy session for baseline assessment and to monitor for changes. Document skin condition, including color, dryness, irritation, and any breakdown.
2. Assess patient’s understanding of normal vs. abnormal skin reactions: Evaluate patient’s knowledge about expected skin reactions to radiation therapy (e.g., erythema, dryness) versus signs of more severe reactions requiring medical attention (e.g., blistering, open areas, drainage).
3. Assess patient’s current skin care practices: Inquire about patient’s current skin care routine in the radiation treatment area, including products used and frequency of cleansing.
4. Pain/Discomfort Assessment: Assess patient’s level of skin irritation, itching, or pain in the radiation treatment area using a pain/symptom scale.

Interventions:

1. Moisturize after treatments: Instruct patient to apply a non-irritating, fragrance-free, lanolin-free moisturizer to the radiation treatment area after each radiation session and as needed to keep skin moisturized. Avoid applying lotions immediately before treatment.
2. Keep the skin clean and dry: Advise patient to cleanse the radiation treatment area gently with warm water and mild soap daily. Pat skin dry gently; avoid rubbing. Avoid deodorant, powders, or perfumes in the treatment area unless specifically approved by radiation oncology team.
3. Do not use abrasive cleaners on the skin: Instruct patient to avoid using antibacterial soaps, alcohol-based products, or harsh scrubs on the treated skin, as these can further dry and irritate the skin.
4. Wear loose clothing and a comfortable bra: Recommend patient wear loose-fitting, soft cotton clothing to minimize friction in the radiation treatment area. If patient wears a bra, advise choosing a soft, non-underwire bra.
5. Avoid direct sun exposure: Educate patient to protect the radiation-treated skin from direct sun exposure. Advise covering the area with loose clothing or using non-irritating sunscreen (SPF 30 or higher) if sun exposure is unavoidable, as per healthcare provider recommendations.
6. Patient Education on Skin Care: Provide patient with written and verbal instructions on skin care during radiation therapy, including cleansing, moisturizing, clothing recommendations, and sun protection. Emphasize importance of reporting any worsening skin reactions to the radiation therapy team promptly.
7. Ongoing Skin Assessment and Monitoring: Continue to assess skin condition at each radiation treatment session. Report any significant skin reactions or breakdown to the radiation oncologist or nurse. Implement additional skin care measures as prescribed.

These care plan examples illustrate how skin care nursing diagnosis guides the development of individualized and goal-directed care, ultimately contributing to improved patient outcomes and skin health.

References

• Gray, M., Giuliano, K. K., Kennedy, K. N., & National Pressure Ulcer Advisory Panel (NPUAP). (2012). National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide.
• Registered Nurses’ Association of Ontario (RNAO). (2016). Risk Assessment and Prevention of Pressure Ulcers (Revised).
• Bryant, R. A., & Nix, D. P. (2015). Acute & Chronic Wounds: Current Management Concepts (5th ed.). Elsevier Mosby.
• Woo, K. Y., Sibbald, R. G., & Krasner, D. L. (2018). Chronic Wound Care: A Problem-Based Learning Approach. Wolters Kluwer.
• LeMone, P., Burke, K., Bauldoff, G., & Gubrud, P. (2015). Medical-Surgical Nursing: Critical Thinking in Patient Care (6th ed.). Pearson.
• Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.). Wolters Kluwer.
• Perry, A. G., Potter, P. A., & Ostendorf, P. S. (2018). Clinical Nursing Skills & Techniques (9th ed.). Elsevier Mosby.
• World Union of Wound Healing Societies (WUWHS). (2016). Consensus Document: Wound Bed Preparation in Practice. Wounds International.
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (n.d.). Diabetic Neuropathy. Retrieved from https://www.niddk.nih.gov/health-information/diabetes/diabetes-complications/diabetic-neuropathy
• American Cancer Society. (n.d.). Radiation Therapy Side Effects. Retrieved from https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/radiation/radiation-therapy-side-effects.html
• The American Society of Colon and Rectal Surgeons. (n.d.). Ostomy Guide. Retrieved from https://fascrs.org/patients/disease-condition/ostomy-guide
• American Burn Association. (n.d.). Burn Facts and Figures. Retrieved from https://ameriburn.org/burn-prevention/burn-safety-resources/burn-facts-figures/
• National Pressure Injury Advisory Panel (NPIAP). (n.d.). Pressure Injury Stages. Retrieved from https://npiap.com/page/PressureInjuryStages
• Braden, B. J., & Bergstrom, N. (1988). A conceptual schema for the study of the etiology of pressure sores. Rehabilitation Nursing, 13(1), 8-12.

This comprehensive guide provides a thorough understanding of skin care nursing diagnosis, equipping nurses with the knowledge and tools to deliver exceptional patient care and promote optimal skin health. By integrating systematic assessment, evidence-based interventions, and individualized care planning, nurses can significantly impact patient outcomes and prevent complications related to impaired skin integrity.