Skin is a major barrier to infection and tissue damage; it protects our body from external stimuli such as heat or cold. Nurses are responsible for assessing patients’ skin conditions and providing appropriate treatment to ensure that their skin remains healthy with good integrity.
This post will explore nursing diagnosis, interventions, and care plans for impaired skin integrity. The first thing to remember is that prevention is key in maintaining healthy skin with good blood flow and function and keeping it free of bacteria and other irritants, which can cause infections like MRSA.
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Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students, for learning purposes only, and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.
Skin is the body’s largest organ and comprises three main layers: epidermis, dermis, and subcutaneous tissues. The outermost layer of skin known as the stratum corneum protects the environment through its barrier function. The main component of this layer is keratin, a protein involved in healing and wound repair. The stratum corneum forms a barrier to water loss and is also the site for cell renewal through dendritic cells and Langerhans cells (immune system components).
Impaired skin occurs when the skin’s protective barrier has been compromised. The National Council Licensure Examination (NCLEX) defines impaired skin integrity as “a disruption in the permeability or continuity of one or more components of the integumentary system, which may result in harmful levels of external factors such as bacteria, heat, chemicals, and moisture coming into contact with body tissues.” Impaired Skin Integrity can occur from many sources: for example, burns on different stages, pressure ulcers, dermatitis and eczema.
Several factors, including; can cause impaired skin integrity
Infection: Bacteria can enter the body through broken skin; this is more common if there are open wounds.
Poor Skin Care: This may happen when the patient does not wash regularly or often, use soap that is too harsh, or over-use moisturizers that clog up pores.
Pressure and Friction: This occurs when the skin is pushed against by clothing, equipment or bedding.
Chemical Injury: This may occur due to touching poisonous plants or exposure to chemicals such as detergents, cleaning products, over-the-counter medications, and essential oils.
Injury: This may occur from an accident, such as a burn or being bitten by an insect.
Other Causes: Pressure ulcers, urinary incontinence, or dermatitis.
Unknown: The cause of the injury is unknown and may be due to surgery, radiation therapy, excessive exposure to sunlight or certain medications.
Risk Factors for Impaired Skin Integrity:-
1. Age: Older adults are more prone to skin damage as their skin becomes thinner and more fragile.
2. Diabetes: Patients with diabetes are more prone to infections, more likely to acquire foot and leg ulcers and may have problems with healing.
3. Heart Disease: The cardiac patient is at a high risk of skin breakdown due to reduced circulation, leading to poor wound healing; also, surgery such as angioplasty or by-pass can cause skin injury.
4. Hyperglycemia: Diabetic patients who suffer from hyperglycemic episodes are at a higher risk of developing skin injuries.
5. Immunocompromised Patients: These include patients undergoing organ transplantation, chemotherapy, or prolonged steroid use; these individuals are more prone to infections, and their immune system is weakened.
6. Illness: This may be an acute illness such as influenza or a chronic disease such as AIDS, multiple sclerosis or diabetes mellitus; these individuals are more at risk for infection and have difficulty healing wounds.
7. Lack of Mobility: Patients who use wheelchairs to get around are more prone to pressure sores.
8. Poor Nutrition: Malnourished patients may have a poor immune response and reduced cell growth, affecting how well they heal or repair wounds.
Skin Integrity is an actual diagnosis in the NANDA-I (Nursing Assessment and Diagnosis for Interventions). You can read more about it here.
The following are some of the main diagnoses that deal specifically with impaired skin integrity:
Impairment in skin integrity is a common condition that all nurses can encounter. This nursing diagnosis covers the full range of first, second and third-degree burns and their effects on the body. Causes include but are not limited to; electrocution, fire, sunburns, radiation therapy, exposure to chemicals, being scalded or having boiling water spilt on the skin.
Pressure ulcers are areas of localized tissue injury that can be painful and lead to serious complications if left untreated. By definition, a pressure ulcer is an area of damaged tissue resulting from unrelieved pressure. The most common sites for pressure ulcers are the sacrum, heels and hips. Risk factors for developing a pressure ulcer include incontinence, poor nutrition, immobility, and decreased sensation in the area of injury, which leads to unawareness of tissue damage and blood supply problems.
Radiation dermatitis is a common complication of radiation therapy. Radiation is used to treat cancer and may also be given as palliative care for patients with chronic illnesses such as fibromyalgia, multiple sclerosis or end-stage renal failure. It can cause different reactions, from redness and itching in mild cases to blistering peeling skin layers in severe cases. The areas most commonly affected include the palms and soles, groin area, anus and around the mouth.
Signs: These are abnormalities that one can observe directly from the patient and includes, but is not limited to, the appearance of skin changes; location and size of ulcerations; type of ulceration (pressure, friction or thermal); evidence of infection.
Symptoms: These are abnormalities that cannot be observed directly from a patient but are reported by the patient, family members or nurses. Symptoms may include pain, odor or drainage from ulceration.
The signs and symptoms for impaired skin integrity seen in a physical assessment of the skin would be: Signs: (Observed by a nurse; reported by the patient.) Possible Early Warning of an Impending Problem
Redness/Edema: Large area of redness or swelling of the skin.
Pain: The patient may report pain related to a change in skin color, warmth, redness and swelling that occurs from ulceration.
Moisture Loss: Skin feels rough, dry and brittle; pliable tissue becomes spongy and painful to touch. It may appear pale, cool or clammy with peripheral cyanosis and capillary refill greater than 2 seconds (for pale skin).
Pain on touch: Tissue, when touched, feels tender, spongy, sensitive or painful.
Patients at risk for developing impaired skin integrity have poor peripheral circulation, wounds or ulcerations in the area that is difficult to reach, and dressings can only be applied by nurses who use wheelchairs.
Nursing interventions are essential to maintain skin integrity, and they include:
1. Assess the skin for any changes in color, temperature, moisture loss or evidence of inflammation which are all early warning signs that there is a problem with impaired skin integrity; this would require an immediate response by the nurse, who will then consult the physician.
2. Provide the patient with information on how to protect their skin from a further breakdown; this includes applying a barrier cream or ointment and advising the individual to avoid irritants such as excess moisture, heat, friction, pressure and shearing.
3. Maintain cleanliness of the skin by washing it frequently with warm soapy water; pat or blot the skin dry with a clean linen towel; do not rub the area.
4. Apply protective skins lotions or creams to protect the individual from external and internal factors; this may include an antimicrobial lotion if there is drainage from ulceration.
5. Advise patients on proper maintenance of their skin integrity and the importance of reporting any changes in their skin such as increased pain, redness, swelling or drainage; this would require further assessment by a healthcare professional.
5. Provide education to patients and family members on protecting the individual from further impairment of their skin integrity; this should include using protective moisturizers or creams that help keep the skin soft and supple.
8. Assist patient to avoid any factors which may cause further breakdown of the skin such as friction, pressure or shearing; this includes ensuring that shoes fit properly and there is no excess rubbing against the skin from their clothing.
9. Provide a therapeutic environment for all patients with impaired skin integrity whereby they are free from undue pressure, friction or shearing of their skin.
10. Encourage patients to practice self-care techniques that will prevent further breakdown of the skin as well as promote wound healing and reduce pain; this includes proper hygiene practices such as daily bathing, changing bedsheets twice a week, turning at least every two hours during sleep time and moving about as much as possible.
11. Maintain skin awareness and promote patient education on how to recognize signs of impairment of the skin integrity. This includes advising individuals who have peripheral vascular disease (PVD) to notice if their feet feel cold or numb, are unusually pale or cool to touch, if they have a slow capillary refill observable via pulse oximetry, or are swollen; they would then need to report this information to their physician.
12. Promote the importance of a healthy lifestyle for patients with impaired skin integrity by encouraging them to maintain adequate nutrition and hydration and engage in regular exercise such as walking.
13. Maintain good personal hygiene, including maintaining good hand hygiene and regular schedule time for staff to wash their hands with soap and water.
14. Encourage patients to keep an open line of communication with all healthcare professionals regarding any concerns they may have or if they notice any further breakdown in their skin integrity; this would include a change in the color, odor or amount of drainage from a wound.
15. Perform assessments of skin integrity according to a standardized protocol and report any findings to the attending physician; this should include recording the date, time and nature of the observation and any changes that have occurred, such as increased redness, pain or drainage from ulceration.
16. Record leg ulcer assessment data according to standardized protocol; this includes the site of ulceration, size and number of ulcers, presence or absence of fluctuance, and color, odor and amount of drainage from ulcerations.
Which Nursing Intervention Should Be Applied to a Client With a Nursing Diagnosis of Risk for Skin Integrity Impairment Related to Immobility?
1. Position the individual in a semi-recumbent position within their bed or chair with pillows placed beneath their head and shoulders; this should provide comfort and promote patient mobility.
2. Provide patients at risk for skin integrity impairment due to immobility with regular turning, positioning and repositioning.
4. Position the individual in a semi-reclining position with their feet elevated at least 30 degrees above the level of their heart; this should be done to maintain blood flow to legs and feet and prevent swelling from occurring.
5. Apply heat such as warm, moist packs or hot, moist towels to cold, pale or cool areas to touch; this will promote peripheral blood flow and healing of the skin.
10. Ensure that patients at risk for pressure sores receive adequate nutrition and hydration and have access to regular exercise such as walking to increase their mobility and prevent further breakdown of their skin integrity.
Which Nursing Measure Should Be Applied to a Client With Impaired Skin Integrity Related to Pressure Ulcers?
This focus of nursing is on the basic principles and interventions required for providing holistic and comprehensive care for clients with pressure ulcers. The following are fundamental aspects in the promotion of wound healing:
1. Perform assessments of skin integrity according to a standardized protocol, including looking for the following characteristics of a pressure ulcer:
2. Observe for any signs and symptoms of increased pain, including guarding, flaring, or rubbing the skin.
3. Assess changes in vascular status such as pallor, cyanosis, oedema and other signs of decreased tissue perfusion related to impaired circulation.
4. Assess for changes in tissue perfusion related to impaired circulation, including altered sensation and turgor, color and temperature of skin related to decreased peripheral blood flow.
5. Evaluate the patient’s nutritional status; this includes assessing for signs of malnutrition and dehydration and providing support with nutrition, hydration, and the promotion of skincare to prevent a further breakdown in tissue integrity.
6. Identify and assess any new or worsening deficits in function related to impaired mobility due to skin breakdown; this includes the ability to ambulate, transfer, and perform ADLs independently.
7. Assess for the presence of detrusor overactivity; this is the abnormal contraction of muscles in the bladder wall that causes involuntary urine loss.
8. Assess for urinary frequency and urgency and changes in output quantity or character, dysuria, suprapubic pain, hesitancy or retention related to detrusor overactivity; this includes educating the individual on ways to decrease incontinence the use of medication and bladder training.
1. Monitor intake and output, as well as urine specific gravity, to assess hydration status.
2. Monitor for signs and symptoms of urinary tract infections, including dysuria, suprapubic pain or fever; this includes educating individuals on ways to reduce the likelihood of developing an infection.
Are there any special considerations for people who have experienced trauma and are concerned about their ability to move through life?
Yes. New interventions are being designed all the time to help with impaired mobility. Some of these innovations include beds that tilt back when an individual tries to sit up in bed on their own, grab bars placed next to toilet seats or bathtubs so that individuals will not slip when standing and moving in or out of the tub, as well as ramps that assist wheelchairs into and out of vans.
Individuals with impaired mobility also need to have their skin/soft tissue assessed regularly for ulcerations. Pressure areas must be treated with dressings such as white wool or sheepskin to prevent breakdowns in this area. Using a long-handled low-temperature metal spatula or butter knife, the affected area should be carefully examined for evidence of redness, heat or swelling and then gently washed with warm water and soap.
Care plan for impaired skin integrity includes;
Assessment findings that determine the type and severity of a wound or lesion. The interventions are based on this determination to promote healing and prevent complications.
The Nurse would most closely monitor the patient’s temperature. This is to determine if the patient has a fever, which indicates an infection causing their skin to break down.
Essential Care and Comfort: The Patient with Impaired Skin Integrity needs all types of interventions, including skincare and comfort measures. They include:
Temperature—the patient needs to be kept at a comfortable temperature in the room and dressed in warm layers when going outside.
Nursing Interventions: The nurse would do any or all of the following;
1) Wash wound/area affected by using a soft cloth, warm water and soap.
2) Apply cold packs to areas of concern
3) Administer pain medication as needed
4) Perform a head to toe assessment—using a complete head-to-toe assessment helps the nurse identify changes in skin integrity or any other condition that might be related to the cause of a breakdown in skin integrity, such as a pressure ulcer that developed in an area that the patient has difficulty moving.
Prevention is essential in the prevention of skin integrity issues.
Suppose a patient has a history of pressure ulcers. In that case, it is important to place them on an appropriate pressure-relieving surface and cushioning devices at all times to prevent further breakdown.
Driving Safety: The patient must be taught how to safely apply, use and remove adaptive devices such as car seats, seat cushions or bathing equipment.
Rest—the patient needs to be able to rest their body.
Improvement of skin integrity starts with good hygiene and involves preventing breakdowns in the skin/soft tissue.
Skincare: This includes washing affected areas and applying cold compresses or warm moist heat to prevent further damage from occurring.
Dressings—the nurse would apply the appropriate dressings such as silver-based products or sterile bandages as indicated.
Risk assessment for skin impairment includes the following;
1) Identifying client problem/condition and any related risk factors: The patient needs to be assessed for risk factors for skin breakdown such as excess moisture, friction and pressure.
2) Risk assessment includes identifying whether a skin break is present or not. If so, then determine its extent, location, cause (if known), and any contributing factors. This will help the nurse develop a plan of action to prevent a further breakdown in this area.
3) If skin breakdown occurs, assess the extent of damage and determine if it is contained or not.
4) The Nurse would conduct all risk assessments using NANDA’s OASIS assessment tool, which provides a complete assessment of the patient’s status.
5) Determine any further assessments that may be needed to determine how to intervene in this situation.
Interventions are changes made by the nurse based on risk assessments conducted by NANDA’s OASIS tool. This includes interventions such as preventing further breakdown of the patient’s skin or soft tissue by using special devices that help reduce any pressure on bony areas such as heels, ankles, hips, elbows and shoulders.
These include pressure areas that are not protected from the weight of bedsore boards or sofas. The elderly and those with disabilities are especially susceptible to these problems, but anyone can have a skin breakdown if enough pressure is applied.
Health Risks: If an ulcer worsens, it can cause further health issues such as staph infections, blood poisoning and even death.
Complications: These include;
Pressure ulcers—these are bedsores that develop when pressure is put on a specific area. Dehydration can make the skin more fragile, making it easier for an ulcer to develop in the patient’s skin.
Impetigo—also known as school sores, is an infection commonly found in the skin. It most often affects children and causes red patches of fluid-filled blisters to form on the individual’s skin.
Impaired Glucose Tolerance (a risk factor for Diabetes)—This risk factor can be caused by many things, including poor nutrition or diabetes. Having impaired glucose tolerance is especially dangerous in the elderly. If the skin breaks down due to lack of care and monitoring, further complications can occur, such as infections and limb loss.
Impaired Liver Function—The liver helps eliminate toxins that enter the body through the skin. If it does not function properly, this can lead to rashes or infections due to a lack of protection.
Impaired Kidney Function—The kidneys are responsible for removing wastes and excess fluid from the body. If they do not function properly, it can cause further skin breakdowns in areas such as the feet or other areas where rashes are common. This can lead to infections such as cellulitis well as more serious infections if the skin breaks down.
Impaired Immune Function—Those at risk for this are those with HIV, AIDS, and the elderly. This causes their immune system to be suppressed, making it easier for infections to occur, such as impetigo or cellulitis.
1) Glucocorticoids: These cortisone-like drugs help in reducing the skin’s susceptibility to infections and other problems.
2) Antibiotics: These can be taken with glucocorticoids or on their own, depending on what type of infection is present. They are usually given if cellulitis is suspected.
3) NSAIDs: Nonsteroidal anti-inflammatory drugs help to reduce pain and to swell in the patient’s skin and underlying tissue.
4) Antihistamines: These are used for allergies or an allergic reaction that has affected the skin, such as a rash or hives. An allergy is an overreaction of the immune system that results in symptoms such as a rash or hives.
5) Antihypertensives: These medications treat high blood pressure and help keep it under control. It is also important for patients with impaired kidney function to have their blood pressure under control because some drugs may affect the kidneys more than others.
6) Oral Supplements: These can be used to repair the patient’s skin and improve their diets, such as calcium, vitamin D and protein. This is important because patients who have poor diets or lack enough protein may develop a problem with malnutrition that makes the skin more susceptible to breakdowns.
7) IV Nutrients: These vitamins can be given through a vein to improve the patient’s skin’s condition. They are used when oral supplements aren’t enough.
8) Wound Treatments: This is useful for treating incisions that need protecting, but not necessarily surgery. It includes bandages and other wound dressings that help keep wounds clean and protect them from further injuries.