Impaired Skin Integrity Nursing Diagnosis and Nursing Care Plans

Impaired Skin Integrity Nursing Care Plans Diagnosis and Interventions

Impaired Skin Integrity NCLEX Review and Nursing Care Plans

The skin is a waterproof, flexible organ that covers the human body. Its three main purposes are: (1) to protect the body, (2) to regulate temperature, and (3) to provide sensation.

The skin is the largest organ of the body and is composed of three layers – the epidermis (outer layer), dermis (middle layer), and hypodermis (innermost layer).

Protecting the integrity of the skin is an important part of holistic nursing care. The regular assessment of skin health is part of the daily evaluation healthcare staff make to ensure holistic care.

Therefore, knowing proper skin care and learning about the possible causes and risk factors that predispose patients to have a breech in their skin integrity are essential in nursing care.

The following are the risk factors that can predispose individuals to skin damage:

  • The use of chemical irritants that may be present in regular household items such as soaps and hair dye
  • Having skin conditions such as dermatitis, pruritus, itching, or any allergic reactions causing skin rashes
  • Very young and very old individuals – extremes in age are associated to frail and sensitive skin
  • Presence of edema
  • Fecal and/or urinary incontinence
  • History of having radiation treatment
  • Having hyperthermia or hypothermia
  • Malnutrition
  • Immobility
  • Immunological deficit
  • Problems with blood circulation
  • Impaired sensation
  • Long-term steroid use
  • Mechanical factors such as pressure, shear, and friction
  • Trauma such as scratches, skin tear, surgical incision
  • Obesity
  • Moisture build-up

Impaired Skin Integrity Nursing Diagnosis

Impaired Skin Integrity Nursing Care Plan 1

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 InterventionsRationales
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 ankleBaseline 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 mobilityPhysical 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 hydrationDehydration can cause further skin injury due to skin dryness.

Impaired Skin Integrity Nursing Care Plan 2

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 InterventionsRationales
Assess skin integrity taking note of color, moisture, texture, and pulses regularlyBaseline 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 timeDiabetes can affect sensation in the extremities. Patients may not notice injury.
Encourage daily moisturization of feetMoisturizing 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 feetPatients may not notice if the water is too hot due to reduced sensation.
Encourage patient to maintain short toenailsLong toenails can cause damage to skin.
Discuss smoking cessation programs if the patient is a smokerVascular 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 medicationsSome 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.

Impaired Skin Integrity Nursing Care Plan 3

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 InterventionsRationales
Assess and record the integrity of skin To provide baseline data to assess care.
Regularly assess condition of bedsoreTo regularly assess progress of healing
Promote regular turning or position changeTo prevent prolonged pressure on one area of the body
Assess the ability of the patient to mobilizeTo assess the extent of physical activities that the patient can do. 
Provide appropriate mattress and cushionPressure 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 neededSacral sores are prone to infection due to its location.
Clean or assist patient in cleaning himself after opening bowelsdue to the location of bedsore, it can easily be reached by stool when bowels are opened.
Refer to physiotherapyPhysiotherapists 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 neededBedsores can be uncomfortable for patients. Providing pain relief will help encourage patients to mobilize and change position.

Impaired Skin Integrity Nursing Care Plan 4

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 InterventionsRationale
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.

Impaired Skin Integrity Nursing Care Plan 5

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 InterventionsRationales
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.  Buy on Amazon

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

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.  Buy on Amazon

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

Disclaimer:

Please follow your facilities guidelines and policies and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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