Impaired Skin Integrity Nursing Diagnosis & Care Plan

Impaired skin integrity refers to a condition where there is damage or disruption to the structure and function of the skin.

It is commonly seen in patients who have compromised skin due to various factors such as trauma, pressure, moisture, or medical conditions.

Causes of Impaired Skin Integrity

1. External factors:
   • Pressure: Prolonged pressure on the skin can lead to the formation of pressure ulcers or bedsores, especially in individuals who are immobile or have limited mobility.
   • Friction: Continuous rubbing or friction against the skin surface can cause skin tears or breakdown.
   • Shearing forces: This occurs when layers of the skin slide in opposite directions, causing damage to the underlying tissues.
   • Moisture: Excessive moisture from perspiration, incontinence, or wound drainage can soften the skin and make it more prone to breakdown.
   • Temperature extremes: Exposure to extreme heat or cold can damage the skin.
2. Internal factors:
   • Poor nutrition: Inadequate intake of essential nutrients, such as proteins, vitamins, and minerals, can impair the skin’s ability to heal and maintain its integrity.
   • Dehydration: Insufficient hydration can lead to dry skin, making it more susceptible to damage and breakdown.
   • Reduced mobility: Immobility or limited mobility can result in pressure points and reduced blood circulation, increasing the risk of pressure ulcers.
   • Age-related changes: As individuals age, their skin becomes thinner, drier, and more fragile, making it more susceptible to damage.
   • Chronic medical conditions: Certain medical conditions like diabetes, vascular diseases, malnutrition, and immunosuppression can compromise skin health and delay wound healing.
   • Medications: Some medications, such as corticosteroids or immunosuppressive drugs, may impair the integrity of the skin.

Signs and symptoms of Impaired Skin Integrity

• Redness (Erythema) of the skin
• Skin Discoloration
• Skin Breakdown
• Swelling (Edema)
• Pain or Tenderness
• Warmth or Coolness
• Exudate
• Itching or Irritation
• Odor
• Delayed Healing

Expected Goals and Outcomes

1. Promote wound healing:
   • The goal is to facilitate the healing process and achieve timely wound closure.
   • Expected outcomes include reduction in wound size, absence of wound drainage or infection, and evidence of granulation tissue formation.
2. Prevent infection:
   • The goal is to minimize the risk of infection, which can delay wound healing and lead to complications.
   • Expected outcomes include absence of signs and symptoms of infection, such as redness, swelling, warmth, and purulent discharge.
3. Relieve pain and discomfort:
   • The goal is to manage pain effectively, promoting the patient’s comfort and well-being.
   • Expected outcomes include reduction in pain intensity, improved ability to perform activities of daily living, and utilization of pain management techniques as needed.
4. Prevent recurrence and further skin breakdown:
   • The goal is to address the underlying causes of impaired skin integrity and prevent future episodes.
   • Expected outcomes include the absence of new or worsening skin breakdown, implementation of preventive measures, and patient and caregiver education on proper skin care and prevention strategies.
5. Improve patient’s quality of life:
   • The goal is to enhance the patient’s overall well-being, including their physical, emotional, and social aspects.
   • Expected outcomes include improved patient satisfaction, increased participation in daily activities, and effective coping strategies.

Nursing Assessment and Rationales

1. Skin:
   • Regularly assess the skin for any signs of redness, discoloration, swelling, warmth, or breakdown.
   • Rationale: Skin assessment helps in identifying early signs of impaired skin integrity, such as pressure areas or early-stage wounds. It allows for prompt intervention and prevention of further damage.
2. Wound:
   • Assess the characteristics of the wound, including size, depth, color, presence of drainage, and signs of infection.
   • Rationale: Wound assessment helps determine the severity of the wound and guides appropriate wound care interventions. It assists in monitoring the healing progress and identifying signs of infection or complications.
3. Pain:
   • Assess the patient’s pain level, location, characteristics, and any factors that aggravate or alleviate the pain.
   • Rationale: Pain assessment helps in understanding the patient’s experience and guides pain management interventions. It ensures the appropriate use of analgesics and non-pharmacological pain relief measures.
4. Nutritional:
   • Evaluate the patient’s nutritional status, including intake, weight changes, and any signs of malnutrition.
   • Rationale: Adequate nutrition is essential for wound healing and maintaining skin integrity. Nutritional assessment helps identify any deficiencies that may impede the healing process and guides interventions to optimize nutrition.
5. Mobility:
   • Assess the patient’s mobility, range of motion, and ability to reposition independently.
   • Rationale: Impaired mobility can contribute to pressure ulcer development. Mobility assessment helps identify patients at risk and guides interventions such as frequent position changes, repositioning aids, and mobility exercises.
6. Hygiene:
   • Evaluate the patient’s hygiene practices, including bathing, incontinence care, and moisture management.
   • Rationale: Proper hygiene practices and moisture management are important for preventing skin breakdown. Hygiene assessment helps identify any factors that may contribute to impaired skin integrity, such as excessive moisture or inadequate cleansing.
7. Psychosocial:
   • Assess the patient’s emotional well-being, self-esteem, and social support systems.
   • Rationale: Impaired skin integrity can have psychosocial implications. Psychosocial assessment helps identify emotional distress, body image concerns, and potential barriers to adherence with the care plan. It guides interventions to address the patient’s psychosocial needs.

Nursing Interventions and Rationales

1. Wound care:
   • Cleanse the wound using appropriate solutions and techniques per hospital protocal.
   • Rationale: Proper wound cleansing helps remove debris, bacteria, and excess exudate, promoting a clean wound bed and facilitating healing.
2. Dressing application:
   • Apply appropriate dressings based on the characteristics of the wound.
   • Rationale: Dressings provide a moist environment, protect the wound from external contaminants, absorb excess exudate, and promote healing.
3. Pressure relief and repositioning:
   • Implement regular turning and repositioning schedules to relieve pressure on vulnerable areas.
   • Rationale: Pressure relief helps prevent pressure ulcers by reducing the prolonged pressure on specific areas, improving blood circulation, and promoting tissue oxygenation.
4. Support surfaces:
   • Utilize specialized support surfaces (e.g., pressure-reducing mattresses, cushions) to distribute pressure and minimize pressure points.
   • Rationale: Support surfaces help reduce pressure and shear forces on the skin, minimizing the risk of pressure ulcer development and supporting wound healing.
5. Nutritional support:
   • Ensure the patient receives a well-balanced diet with adequate protein, vitamins, and minerals.
   • Rationale: Proper nutrition is essential for wound healing and maintaining skin integrity. Adequate intake of nutrients supports collagen synthesis, cellular repair, and overall tissue health.
6. Moisture management:
   • Keep the skin clean and dry, and utilize moisture-barrier creams or products for moisture-associated skin damage.
   • Rationale: Moisture management helps prevent skin breakdown caused by excessive moisture or prolonged exposure to moisture. It reduces the risk of maceration and promotes a healthy skin environment.
7. Education and self-care:
   • Educate the patient and their caregivers on proper skin care, wound management, prevention strategies, and the importance of adherence to the care plan.
   • Rationale: Patient education empowers individuals to take an active role in their own care, promoting self-care and preventing further skin breakdown. It ensures understanding of preventive measures, recognizing signs of worsening condition, and seeking timely healthcare intervention.
8. Pain management:
   • Administer analgesic medications as prescribed and utilize non-pharmacological pain management techniques (e.g., positioning, relaxation techniques).
   • Rationale: Effective pain management promotes patient comfort, reduces stress, and enhances the healing process. It improves the patient’s overall well-being and adherence to the care plan.
9. Monitoring and documentation:
   • Regularly assess and document the wound status, including size, appearance, exudate, and signs of infection.
   • Rationale: Monitoring and documentation provide a baseline for tracking wound healing progress, identifying any changes or complications, and evaluating the effectiveness of interventions. It ensures accurate communication within the healthcare team.

Impaired Skin Integrity Nursing Care Plans

Kawasaki Disease

Nursing Diagnosis: Impaired skin integrity related to edema formation secondary to Kawasaki disease as evidenced by bilateral swelling of the legs and feet and small cut on left ankle.

Desired outcome: Patient will have healed left ankle wound and further skin damage will be prevented.

Impaired Skin Integrity Nursing Interventions

Assess the skin for its integrity, color, moisture and texture.  Kawasaki disease affects the skin and can cause erythematous rashes and edema particularly on the hands, arms, legs, and feet.

Assess the level of edema on the legs and cut on the ankle.  Baseline data will help in the evaluation of progress after interventions are made.

Encourage patient to elevate legs and avoid putting them on a dependent position for a long period of time.   Putting legs on dependent position will worsen leg edema.

Encourage mobility  Physical activity helps promote circulation and fluid drainage.

Dress wounds as needed, avoiding tight, constricting, and sticky dressings.  As needed, wound will need to be dressed and cleaned. Sticky dressings may be difficult to remove and cause further damage.

Encourage patient to avoid wearing constricting clothing.  Tight clothing can further irritate skin damage and rashes.

Encourage proper hydration.  Dehydration can cause further skin injury due to skin dryness.

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Diabetes

Nursing Diagnosis: Risk for impaired skin integrity due to decreased circulation from popliteal artery obstruction secondary to Type 2 diabetes

Desired outcome: Patient’s foot will remain intact while waiting for vascular treatment

Impaired Skin Integrity Nursing Interventions

Assess skin integrity taking note of color, moisture, texture, and pulses regularly.  Baseline data is needed for prompt evaluation after interventions are made. It will also help in the regular assessment in the progress of nursing care.

Encourage use of footwear at all time.  Diabetes can affect sensation in the extremities. Patients may not notice injury.

Encourage daily moisturization of feet.  Moisturizing feet everyday provides opportunity to assess the integrity of the feet daily. Also, moisturizing the feet helps keep its intact skin integrity.

Check water temperature when washing feet.  Patients may not notice if the water is too hot due to reduced sensation.

Encourage patient to maintain short toenails.   Long toenails can cause damage to skin.

Discuss smoking cessation programs if the patient is a smoker.  Vascular problems are worsened by smoking, also, the success of vascular treatments such as angioplasty can be affected if the patient will not stop smoking after having it.

Monitor and maintain a normal blood sugar level.  Hyperglycemia and hypoglycemia can both affect vascular health.

Review medications.  Some medications used in type 2 diabetes can predispose patients to foot problems though research is still not conclusive on this matter.

Prepare patient for vascular treatment.  Depending on the medical plan, the patient may have to undergo surgical treatment.

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Pressure ulcers / Bed sores

Nursing Diagnosis: Impaired skin integrity (pressure ulcers) secondary to decreased mobility as evidenced by presence of stage 2 pressure ulcer on the sacrum.

Desired Outcome: Patient’s bedsore will show optimal healing, and further bedsores will be prevented.

Impaired Skin Integrity Nursing Interventions

Assess and record the integrity of skin.  To provide baseline data to assess care.

Regularly assess condition for bedsores.  To regularly assess progress of healing

Promote regular turning or position change.  To prevent prolonged pressure on one area of the body

Assess the ability of the patient to mobilize.  To assess the extent of physical activities that the patient can do. 

Provide appropriate mattress and cushion.  Pressure release mattresses and cushions are helpful to prevent sores from occurring and they help spread equal pressure to the body when sitting and lying down. 

Clean and dress bedsore as needed.  Sacral sores are prone to infection due to its location.

Clean or assist patient in cleaning himself after opening bowels.  due to the location of bedsore, it can easily be reached by stool when bowels are opened.

Refer to physiotherapy.  Physiotherapists can help assess mobility and advise on positioning and mobility aids

Change sheets regularly and avoid folds and creases.  Creases on sheets can cause pressure on the skin.

Provide pain relief as needed.  Bedsores can be uncomfortable for patients. Providing pain relief will help encourage patients to mobilize and change position.

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Impetigo

Nursing Diagnosis: Impaired Skin Integrity related to infection of the skin secondary to impetigo, as evidenced by red sores around the area of the nose and mouth, discharge from the sores for a couple of days, development of yellowish-brown crust, mild itching, pain and soreness

Desired Outcome: The patient will re-establish healthy skin integrity by following treatment regimen for impetigo.

Impaired Skin Integrity Nursing Interventions

Assess the patient’s skin on his/her whole body.   To determine the severity of impetigo and any affected areas that require special attention or wound care.

Isolate the patient in his/her room, at home ideally for 10 days.  Impetigo is an infectious/ communicable skin disease. The patient needs to be isolated ideally for 7 to 10 days after starting treatment.

The affected area should be soaked first in warm water to remove the scabs, wet compresses may also be used. This is followed by the application of the prescribed antibiotic cream or ointment directly to the affected areas.  Removal of scabs prior to applying the topical antibiotic promotes good absorption of the medication.

Administer antibiotics as prescribed. Ensure that the patient finishes the course of antibiotic prescribed by the physician.  Impetigo is generally treated through the use of antibiotic therapy. If the infection is mild and have not spread to other areas of the body, the sores can be treated through the use of over-the-counter antibiotic cream containing bacitracin, as a home remedy. Application of non-stick bandages over the affected areas can also help prevent the spread of sores and further infection. The doctor may also prescribe oral antibiotic drugs in patients who have a lot of impetigo sores. Even if the symptoms have already improved and healing is evident, it is still important to finish the course of antibiotic therapy to prevent recurrence of infection and antibiotic resistance.

Educate the patient and caregiver about proper wound hygiene through washing the sores with soap and water.  Advise the patient and caregiver to prevent scratching the affected areas.  It is important to maintain the cleanliness of the affected areas by washing with mild soap and water. The sores may cause mild itching, but it is advisable to prevent the child from scratching the affected areas to prevent worsening of the infection.

Teach the patient/ caregiver the proper application of non-stick bandages over the affected areas can also help prevent the spread of sores and further infection.  Proper application of non-stick bandages over the affected areas can also help prevent the spread of sores and further infection.

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Necrotizing Fasciitis/ Skin Gangrene

Nursing Diagnosis: Impaired Skin Integrity related to infective process of necrotizing fasciitis as evidenced by positive tissue biopsy result, gangrenous skin tissue, erythema, and pain on the affected site.

Desired Outcome: The patient will be able to experience optimal wound healing and avoid the spread of infection to the rest of the skin to preserve its integrity.

Impaired Skin Integrity Nursing Interventions

Assess vital signs and monitor the signs of infection.   To establish baseline observations and check the progress of the infection as the patient receives medical treatment.

Prepare the patient for surgical debridement.  It involves the resection of the gangrenous tissue to prevent further spread of the condition to other vital organs. It involves extensive and complete removal of dead tissue even beyond the area of necrosis.

Place silver-containing dressings on the affected site/s after each debridement.  Dressings containing silver compounds are helpful in addressing topical and direct antibiotic treatment of the affected tissues.

Administer the prescribed antibiotics.  To treat the underlying bacterial cause of necrotizing fasciitis.

Encourage proper hand hygiene and skin care.  To preserve integrity to the rest of the skin.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. 

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier.

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. 

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. 

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