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.
In this article:
- Causes (Related to)
- Signs and Symptoms (As evidenced by)
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
Causes (Related to)
The following are common causes of impaired skin integrity:
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
- Wounds
- Cognitive impairment
- Moisture/secretions
- Shearing/friction/pressure
Signs and Symptoms (As evidenced by)
Impaired skin integrity can manifest with a variety of signs and symptoms. In a physical assessment, a patient with impaired skin integrity may present with one or more of the following:
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
The following are common nursing care planning goals and expected outcomes for impaired skin integrity:
- 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
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to impaired skin integrity.
1. Conduct a thorough skin assessment.
A comprehensive head-to-toe skin examination should be carried out upon admission, during unit transfers, and once every shift. This is done to monitor and prevent skin breakdown during admission. Particular areas the nurse should take care to examine include any points at high risk of skin breakdown such as the heels and coccyx.
2. Utilize Braden Skin Assessment.
An evidence-based approach for assessing the risk of pressure injuries is the Braden Scale. The following are the six criteria on which the patient is assessed:
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction
- Shear
Note: A score is computed from 6 to 23. The likelihood of tissue damage increases with decreasing score. Institutional policy will determine the frequency that the braden scale is required, but the nurse should also use the scale when they think there is a risk of skin breakdown.
3. Assess circulatory status.
Examine the circulation, sensation, and turgor of the skin. The risk of tissue injury is increased by poor skin turgor, diminished feelings (nerve damage), and poor circulation (loss of blood flow indicated by reddish or purple skin discoloration of lower legs and palpable pulses).
4. Assess the activity level and mobility.
Observe the patient’s ability to walk and move in bed. Skin breakdown is typical in patients who cannot walk or have trouble shifting their weight in a chair or bed. Patients who use restraints are also at high risk of skin breakdown.
5. Determine risk of skin breakdown related to moisture.
Note the patient’s increasing perspiration and incontinence. Evaluate the patient’s body secretions, such as:
- Sweat/ perspiration
- Urine
- Stool
Patients who are incontinent are at a high risk of skin breakdown due to moisture buildup.
6. Evaluate the patient’s ability to care for themselves.
Note the patient’s ability to manage incontinence and self-care. Patients who are incontinent or unable to ask for help to go to the bathroom require constant monitoring to maintain clean, dry skin.
7. Describe the wound.
Accurate recording of observed wounds and skin breakdown is necessary to track the healing process and the efficacy of treatments. In addition to providing thorough descriptions of drainage, the periwound region, odor, and any tunneling or undermining, wounds must be precisely staged in terms of length, width, and depth. It is advisable to take a picture for comparative purposes.
8. Assess the patient’s nutrition and hydration.
Monitor the patient’s diet and fluids. Adequate fluids improve oxygen and nutrition delivery to the wound site. Consuming foods and supplements high in protein is crucial for healing bodily tissues.
9. Assess the stoma and ostomy.
A wound care specialist assesses if a newly created stoma is healing properly. They also check the appropriateness of the applied ostomy equipment.
Nursing Interventions
Nursing interventions and care are essential to prevent and treat impaired skin integrity. In the following section, you’ll learn more about possible nursing interventions for a patient with impaired skin integrity.
1. Implement wound care protocols as prescribed.
Apply appropriate wound care protocols depending on the wound’s type, size, and location. Wound care protocols depend on the wound care specialist’s advice or the facility’s policies and procedures.
2. Position the patient comfortably.
Protect the bony prominences, relieving the bone from pressure. Patients who are unable to ambulate should be repositioned at least every two hours or as per the facility’s protocols. The nurse may be guided with a turn clock to cue repositioning of the patient.
3. Ensure adequate skin perfusion.
Use cushions or other positioning devices as a support for the following bony prominences:
- Elbows
- Knees
- Hips
- Heels
4. Determine the patient’s continence and skin moisture.
The nurse should maintain dry, clean skin for the patient. Sweat, stool, and urine irritate the skin. Thus, keeping clothes, bed sheets, and perineal area dry is essential.
5. Alleviate the pressure.
Repositioning and pressure relief are facilitated by a low-air loss mattress that cycles between inflating and deflating to simulate a patient shifting in bed. Make use of air mattresses and the proper equipment. Offloading can be aided by:
- Wedge pillows
- Waffle boots
- Gel overlays on chairs and beds
6. Promote proper nutrition and fluids.
Promote healthy nutrition and hydration. Collaborate with the dietitian to meet the patient’s recommended diet and fluid intake.
7. Protect the skin from further injury.
Ensure protection of the skin, such as wearing socks or non-slip shoes. Patients with compromised neurovascular status (such as diabetic patients) have to protect their feet to prevent skin injuries because they have reduced sensation in their lower legs and feet.
8. Coordinate with a wound/ostomy specialist.
A wound care/ostomy specialist can recommend, evaluate, and give instructions regarding the appropriate wound care protocol.
9. Avoid irritation.
Pastes and powders minimize skin irritation. The stoma’s and any areas exposed to moisture may become irritated. Thus, barrier pastes and powders may be necessary to reduce irritation. For patients with an ostomy, removing the pouch becomes simpler with adhesive removers that do not damage the skin.
10. Manage the ostomy pouch.
Teach patients how to empty and fit their ostomy pouches correctly. Sealing around the stoma to stop leaks and irritation of the peristomal skin can be achieved by carefully sizing the adhesive wafer and fitting the pouch system. Empty the ostomy pouch when they are ⅓ to ½ full to keep pouches from tearing away from the skin.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for impaired skin integrity.
Care Plan #1
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 3 to stage 2 within 1 month of nursing interventions.
- Patient will be able to maintain skin integrity by keeping the skin dry and clean at the end of the shift.
- Patient will verbalize cooperation and compliance during wound care within 1 hour of nursing intervention.
- Patient will enumerate ways to prevent pressure ulcers within 1 hour of nursing intervention.
Assessment:
1. Assess the skin and wounds regularly.
The 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 skin breakdown is not worsening, such as increased redness. Measurements of wounds should occur at least weekly to monitor for progress.
2. Determine the patient’s mobility.
Determine the patient’s need for assistance to move. Immobility can cause prolonged pressure to bony prominence, resulting in pressure ulcers.
3. Assess the patient’s need for positioning devices.
Bedridden patients may need positioning devices to maintain a particular position to offload bony prominences. Determine the patient’s size and ability to move to know the devices needed.
Interventions:
1. Perform wound care per guidelines and orders.
Wound care differs depending on the type of skin breakdown, location on the body, and wound size. Inadequate or incorrect wound care delays healing and increases the risk for infection.
2. Repositioning and support of bony prominences.
Patients who cannot reposition themselves should be turned in bed on a schedule at least every 2 hours. Bony prominences such as hips, knees, heels, and elbows should be supported with pillows or devices for proper skin perfusion.
3. Keep the skin clean and dry.
Consider incontinence or increased perspiration. Along with a turning schedule, patients should be assessed for any bodily secretions, particularly near the wound. Bed linens, clothing, and any use of adult diapers must be kept dry as urine, feces, and sweat irritate the skin.
4. Use appropriate devices and air mattresses.
Wedge pillows, waffle boots, and gel overlays on beds and chairs can effectively offload. A low-air loss mattress alternates inflating and deflating to mimic the shifting of a patient in bed, which helps reposition and relieve pressure.
5. 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.
Care Plan #2
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 manifest intact skin on the lower extremities at the end of the shift.
- Patient will enumerate ways to prevent skin infection within 1 hour of nursing intervention.
- Patient will maintain skin perfusion by controlled blood glucose at the end of the shift.
- Patient will verbalize understanding of daily skin inspection within 1 hour of nursing intervention.
Assessment:
1. Assess skin for infection.
Redness and open areas of the skin put the patient at risk for infection, such as cellulitis. Monitor for signs of infection, such as:
- Redness
- Purulent drainage
- Warm to touch
- Foul odor
- Swelling
2. Determine the skin perfusion.
Patients with diabetes have decreased skin sensation and skin perfusion. They are at risk for injury since they cannot immediately feel pain once the injury is inflicted. These patients also have compromised blood flow due to blood glucose alterations.
3. Monitor the patient’s blood glucose.
Diabetes increases the chance of infections and other severe complications by slowing down the healing of wounds.
Interventions:
1. Control the blood glucose.
When blood glucose is too high, it can injure the nerves, most often in the legs and feet, causing diabetic neuropathy. Keep glucose levels within a normal range to prevent worsening neuropathy, decrease the risk of infection, and promote wound healing.
2. Educate on diabetic neuropathy and the importance of daily skin checks.
Diabetes results in symptoms of burning, numbness, and reduced sensation. It puts the patient at risk for impaired skin integrity if they cannot feel normal sensations of pain or pressure.
3. Ensure foot protection at all times.
Due to decreased sensation in the lower legs and feet, the patient must keep their feet protected to prevent skin injury.
Care Plan #3
Diagnostic statement:
Impaired skin integrity related to surgical incision and stoma creation to the abdomen.
Expected outcomes:
- Patient will verbalize understanding of preventing the skin irritation to skin surrounding the stoma within 1 hour of nursing intervention.
- Patient will manifest a moist and pinkish stoma at the end of the shift.
- Patient will enumerate ways to protect the stoma from skin breakdown within 1 hour of nursing intervention.
- Patient will verbalize the proper fitting and emptying of the ostomy pouch within 1 hour of nursing intervention.
Assessment:
1. Determine the indication for surgery or stoma.
A stoma is an abdominal incision created via surgery that permits the direct removal of waste from the body into a collection bag via the end of the colon. It is important that the nurse understands the underlying pathophysiology that led to the need for a stoma.
2. Assess incision and stoma.
Stoma following surgery should be moist and pink-red. It should protrude from the incision, though it may be swollen and will reduce in size in the weeks following surgery.
3. Determine the patient’s diet.
Nutrition and hydration play an essential role in wound recovery. Refer the patient to a dietitian for dietary evaluation and nutritional support.
Interventions:
1. Collaborate with a 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.
2. Create meal plans with the patient.
Educate the patient on recommended diets to control output. Diet considerations may depend on each individual with some degree of trial and error. A low-residue diet is 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 of leakage.
3. Minimize skin irritation.
Encourage the use of pastes/powders to prevent irritation. Barrier pastes and powders may be necessary to prevent leaking around the stoma, which can irritate the surrounding skin. Adhesive removers make taking the pouch off easier without damaging the skin.
4. Educate the patient on properly fitting and emptying 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 from ⅓ to ½ full to prevent pulling away from the skin.
Care Plan #4
Diagnostic statement:
Impaired skin integrity related to burn wounds.
Expected outcomes:
- Patient will manifest skin restoration as evidenced by tissue regeneration within six months.
- Patient will maintain intact wound dressing at the end of the shift.
- Patient will verbalize cooperation and compliance during wound care at the end of the shift.
- Patient will enumerate ways to prevent skin infection within 1 hour of nursing intervention.
Assessment:
1. Assess the severity of the burn wound.
Skin is known to be the largest physical barrier against infection. The severity of the burn wound indicates the risk of infection.
2. Determine the degree of burn.
The degree of the burn describes the depth of the affected skin. There are four categories, including:
- First-degree burns (superficial)
- Second-degree burns (partial-thickness)
- Third-degree burns (full-thickness)
- Fourth-degree burns (subdermal)
Note: Fourth-degree burn is the most severe due to the involvement of subcutaneous tissue, tendon, and bone.
3. Assess the patient’s knowledge about wound dressing.
Patient’s outlook on burn wound dressing may affect their compliance with treatment. Burn injuries are excruciating and take a long time to heal. The discomfort is exacerbated by the need to change dressings often to avoid infection.
Interventions:
1. Apply wound dressing.
Protect the skin breakdown by proper wound dressing application. Covering the burns prevents infection and further skin damage. It is essential to maintain aseptic technique as burn patients are at very high risk of infection.
2. Cleanse the wound regularly.
Wound debris and exudates slow down healing time and worsen skin impairment. Wound debridement promotes skin regeneration and optimizes wound healing. Depending on the nurse’s training and the debridement technique they may perform or just assist in debridement. It can be done through these techniques:
- Surgical debridement
- Hydrosurgical debridement
- Autolytic/Enzymatic debridement
- Mechanical debridement
- Biologic debridement
3. Promote new skin growth.
Skin tissue engineering aims to develop a specialty of burn surgery. It aims to produce new, live tissue that can completely replace the affected skin. It requires good blood flow to promote new skin growth.
4. Encourage patient compliance in wound dressing.
People with burn wounds may find dressing changes to be highly unpleasant. This pain may contribute to feelings of worry or anxiety. The nurse should offer sufficient pain control prior to changing the dressing. The nurse can also educate the patient that compliance with wound treatment will make for faster wound healing and prevention of infection.
References
- Al Aboud, A. M., & Manna, B. (2023, April 19). Wound pressure injury management – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved November 2023, from https://www.ncbi.nlm.nih.gov/books/NBK532897/
- Anyanwu, J. A., & Cindass, R. (2023, May 29). Burn debridement, grafting, and reconstruction – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved November 2023, from https://www.ncbi.nlm.nih.gov/books/NBK551717/
- Carlin, A. S. (2022, September 12). Essentials of wound care: Assessing and managing impaired skin integrity. RCNi | Information and inspiration for nurses. Retrieved November 2023, from https://journals.rcni.com/nursing-standard/evidence-and-practice/essentials-of-wound-care-assessing-and-managing-impaired-skin-integrity-ns.2022.e11964/abs
- 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.
- Ernstmeyer, & Christman (Eds.). (2022, February 17). 10.2: Integumentary basic concepts. Medicine LibreTexts. Retrieved November 2023, from https://med.libretexts.org/Bookshelves/Nursing/Nursing_Fundamentals_(OpenRN)/10%3A_Integumentary/10.02%3A_Integumentary_Basic_Concepts
- 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
- Implementation of turning clocks for pressure ulcer prevention and management. (2018, May 8). HSO Health Standards Organization. Retrieved November 2023, from https://healthstandards.org/leading-practice/implementation-of-turning-clocks-for-pressure-ulcer-prevention-and-management/
- 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/
