The skin is the body’s outermost defense system that keeps pathogens from entering and causing illness. When the skin is compromised due to cuts, abrasions, ulcers, incisions, and wounds, it allows bacteria to enter causing infections. It is important that nurses understand how to assess, prevent, treat, and educate patients on impaired skin integrity.
Causes: (Related to)
Internal:
- Poor nutritional state (obesity, emaciation, dehydration)
- Edema
- Impaired circulation
- Neuropathy
- Disease processes (diabetes, autoimmune disorders)
External:
- Hyperthermia
- Hypothermia
- Radiation
- Chemicals
- Extremes in age
- Physical immobilization/bedrest
- Paralysis
- Surgery
- Cognitive impairment
- Moisture/secretions
- Shearing/friction/pressure
Signs and Symptoms (As evidenced by)
Subjective: (Patient reports)
- Pain
- Itching
- Numbness to affected and surrounding skin
Objective: (Nurse assesses)
- Changes to skin color (erythema, bruising, blanching)
- Warmth to skin
- Swelling to tissues
- Observed open areas or breakdown, excoriation
Expected Outcomes
- Patient will maintain intact skin integrity
- Patient will experience timely healing of wounds without complications
- Patient will demonstrate effective wound care
- Patient will verbalize proper prevention of pressure injuries
Nursing Assessment for Impaired Skin Integrity
| Intervention | Rationale |
| Complete skin assessment | A thorough head-to-toe skin assessment should be performed on admission, transfer between units, and once per shift to monitor and/or prevent skin breakdown. |
| Braden Skin Assessment | The Braden Scale is an evidence-based tool that predicts the risk for pressure injuries. The patient is scored on six categories: Sensory perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear. A score is calculated between 9-23. The lower the score, the higher the risk of tissue injury. A Braden Skin Assessment should be completed by the nurse with every new admission, though some facilities require it on every shift. |
| Assess skin turgor, sensation, and circulation | Poor skin turgor, decreased sensations (nerve damage), and poor circulation (lack of blood flow assessed via palpation of pulse sites as well as observed by purplish or ruddy discoloration of lower legs) increase the risk of tissue damage. |
| Monitor ambulation status and bed mobility | Patients who cannot walk or cannot shift their weight in a chair or bed are at a higher risk for skin breakdown. Patients who may have adequate mobility but are under the use of restraints are also at risk. |
| Consider incontinence or self-care deficit | Patients who are unable to ask for assistance to use the bathroom or are incontinent need frequent monitoring to keep skin dry and clean. |
| Proper documentation of wounds | Observed wound and skin breakdown requires accurate documentation in order to monitor the healing and effectiveness of interventions. Wounds must be staged correctly including length, width, and depth with detailed descriptions of drainage, peri-wound area, odor, and any tunneling or undermining. A photograph should be taken for baseline comparison. |
Nursing Care Plans for Impaired Skin Integrity
Nursing Care Plan 1
Nursing Diagnosis: Impaired skin integrity related to immobility as evidenced by stage 2 pressure ulcer to the sacrum
Desired outcome: Patient will not experience worsening of pressure ulcer
| Intervention | Rationale |
| Perform wound care per guidelines and orders | Wound care differs depending on the type of skin breakdown, location on the body, and size of the wound. Inadequate or incorrect wound care delays healing and increases the risk for infection. |
| Continued assessment of skin and wounds | Skin at risk for breakdown should be closely monitored at least once a shift. Observed wounds should be monitored to ensure dressings are intact or that skin breakdown is not worsening, such as increased redness. Measurements of wounds should occur at least weekly to monitor for progress. |
| Repositioning and support of boney prominences | Patients who cannot reposition themselves should be turned in bed on a schedule at least every 2 hours. Boney prominences such as hips, knees, heels, and elbows should be supported with pillows or devices to allow for proper skin perfusion. |
| Keep the skin clean and dry | Consider incontinence or increased perspiration. Along with a turning schedule, patients should be assessed for any bodily secretions. Bed linens, clothing, and any use of adult diapers must be kept dry as urine, feces, and sweat are irritating to the skin. |
| Use appropriate devices and air mattresses | Wedge pillows, waffle boots, and gel overlays to beds and chairs can be effective in offloading. A low-air loss mattress alternates inflating and deflating to mimic the shifting of a patient in bed which helps in repositioning and relieving pressure. |
| Encourage nutrition and hydration | Proper intake of fluids increases oxygen and nutrient delivery to the wound bed by increasing the blood volume. Intake of high protein foods and supplements is essential for repairing body tissues. |
Nursing Care Plan 2
Nursing Diagnosis: 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
Desired outcome: Patient will verbalize understanding of daily skin inspection
| Intervention | Rationale |
| Educate on diabetic neuropathy and the importance of daily skin checks | When blood glucose is uncontrolled it can injure the nerves, most often in the legs and feet causing diabetic neuropathy. This results in symptoms of burning and numbness as well as reduced sensation. This puts the patient at risk for impaired skin integrity if they cannot feel the normal sensations of pain or pressure. |
| Ensure socks or non-slip footwear is worn at all times | Due to decreased sensation to the lower legs and feet, the patient must keep feet protected to prevent skin injury. |
| Maintain normal blood glucose levels | Since neuropathy occurs due to uncontrolled (high) blood glucose, it is imperative to keep glucose levels normal to prevent worsening neuropathy. |
| Assess skin for infection | Redness and open areas to the skin put the patient at risk for infection such as cellulitis. Monitor for signs of infection such as expanding redness, purulent drainage, warmth, odor, and swelling. |
Nursing Care Plan 3
Nursing Diagnosis: Impaired skin integrity related to surgical incision and stoma creation to the abdomen
Desired outcome: Patient will verbalize understanding of preventing skin irritation to skin surrounding the stoma
| Intervention | Rationale |
| Assess incision and stoma | Stoma following surgery should be moist and pink-red in color. It should protrude from the incision, though it may be swollen and will reduce in size the weeks following surgery. |
| Collaborate with wound/ostomy specialist | New stoma creation requires assessment and education from a wound care/ostomy specialist to ensure the stoma is healing properly and the correct ostomy supplies are being used to fit the stoma correctly. |
| Educate on recommended diets to control output | Diet considerations may depend on each individual with trial and error. A low-residue diet is often prescribed initially as the bowel heals. It may be necessary to limit spicy foods, alcohol, and high-fiber foods which can cause diarrhea, potentially increasing output and the risk for leakage. |
| Encourage use of pastes/powders to prevent irritation | Barrier pastes and powders may be necessary to prevent leaking around the stoma which can irritate surrounding skin. Adhesive removers make taking the pouch off easier without damaging the skin. |
| Educate on proper fitting and emptying of the ostomy pouch | Proper measuring of the adhesive wafer and fitting of the pouch system will help with sealing around the stoma to prevent leakage and peristomal skin irritation. Pouches should be emptied when they are ⅓ to ½ full to prevent pulling away from the skin. |
References and Sources
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
- Hovan, H. (2021, January 7th). Understanding the Braden Scale: Focus on Sensory Perception (Part 1). Wound Source. Retrieved October 11th, 2021, from https://www.woundsource.com/blog/understanding-braden-scale-focus-sensory-perception-part-1
- Posthauer, M. E. (2006, March). Hydration Does It Play a Role in Wound Healing? Advances in Skin & Wound Care. Retrieved October 11th, 2021, from https://journals.lww.com/aswcjournal/fulltext/2006/03000/hydration__does_it_play_a_role_in_wound_healing_.7.aspx
- Stoma Skincare. (n.d.). Bladder and Bowel Community. https://www.bladderandbowel.org/bowel/stoma/stoma-skincare/
