Acute Pain

Introduction/Pathophysiology [1,2]

Physical immobility, prolonged bed rest, alterations in nutritional status often result in impaired peripheral circulation, compromising the tissue nutrient delivery and skin integrity. Impaired skin integrity nursing diagnosis and early recognition allows for prompt intervention. Implementing the risk for impaired skin integrity care plan can help prevent further complications, especially discomfort and risk of infections.

Causes[1,2]

  • Prolonged bed rest
  • Edema
  • Decreased tissue perfusion

Symptoms[1,2]

Subjective (client may report)

  • verbal report of pain
  • altered sensation at site if tissue impairment

Objective[1]

  • Skin color changes
  • Skin redness
  • Warmth of skin
  • Skin areas demonstrating impairment

Risk factors[1]:

  • Bed rest
  • Altered circulation
  • Impaired mobility
  • Mechanical factors; shear
  • Obesity

Intervention[1]

Assessment[1]

Collect client history, including risk factors and symptoms (objective and subjective data)

Cardiac Function:

  • Abnormal heart
  • Changes in blood pressure

Respiratory function

  • Changes in breathing

Neurologic/Sensory function

  • Pain
  • Loss of sensation
  • Confusion (risk of infection)

Visual appearance/labs

  • Pallor
  • Redness
  • Breakdown of skin covering bony prominences
  • Pruritic areas
  • Perineum
  • Areas of decreased sensation

Impaired Skin Integrity Nursing diagnosis [1]

Assessment 

Inspect the skin (especially bony prominences, dependent areas, and affected extremity for pallor, redness and breakdown

Rationale: 

Presence of signs and symptoms establishes an actual diagnosis

Risk for impaired skin integrity care plan[1,2]

  • Improve blood flow
  • Minimize tissues hypoxia (massage)
  • Improve myocardial contractility/systemic perfusion
  • Proper positioning of clients, including foam blocks, pillows, bed cradles
  • Prevent complications-risk of infection
  • Provide information about disease/prognosis, therapy needs, and prevention of recurrences

Nursing actions[1,2]

Perform:

  • Skin inspection, noting skeletal prominences, areas of altered circulation, pigmentation, obesity and emaciation
  • Check for edema
  • Remove antiembolism stockings for 30-60 minutes at least twice a day
  • Notify appropriate health care providers if needed-wound care specialist, physician

Provide:

  • Frequent skin care, minimize contact with moisture/excretions
  • Provide gentle massage around the affected areas -red and blanched
    • Avoid the affected area directly as it may cause tissue injury
  • Assistance with active and passive range of motion exercises (ROM)
  • Alternating pressure/egg-crate mattress, pillows,sheepskin elbow/ heel protectors such as gel or foam cushions
    • Reduce pressure to skin, improve circulation
    • Assist client with turning every 2 hours
  • Bed cradle or footboard to relieve pressure from bed linens
  • Tools, such as foam blocks or pillows to help elevate extremities

Avoid:

  • Intramuscular route for medication-impeded drug absorption
  • Tight shoes or slippers- edema may cause shoes to. Fit poorly, increased risk of breakdown due pressure on skin on feet
  • Excessive dryness or moisture as they can damage skin and hasten breakdown

Administer:

  • Supplemental oxygen
  • Antidysrhythmic agents, Anticholinergic agents, pain medications if needed

Monitor:

  • Skin integrity
  • Skin color
  • Edema
  • Possible infection

Encourage:

  • Frequent positions changes in bed/chair-reduces pressure on tissue, improving circulation and reducing the time the area is deprived of blood flow.
  • Keeping bed linens clean and dry

Goals and Outcomes[1,2]

  • Maintain skin integrity/ no skin breakdowns
  • Absence of redness and irritation
  • Demonstrates behaviors/techniques to prevent skin breakdowns

Post intervention evaluation/monitoring [1]

Monitor[1]

  • Skin integrity
  • Skin color
  • Signs of infection-blood test

Future goals [1]

  • Maintain skin integrity
  • Prevent underlying causes
  • Client understanding and demonstration of behaviors and techniques to prevent skin breakdowns

Prevention[1,2]

  • Pressure management to prevent ulceration
  • Check for fit of shoes, slippers and change as needed
  • Control edema; interstitial edema and impaired circulation slow down drug absorption and predispose to tissue breakdown/ development of infection
  • Encourage smoking cessation
  • Educate about tips to conserve energy

Supplemental material

Client case

Client has been admitted in the NICU for 13 days after a stroke accident. Client in not ventilated anymore. Client mentions he is experiencing warmness and pain in the lower back. Client’s BMI is 37.5 and he also suffers from stage 3 kidney disease.

Questions: 

Based on the client case, what factors are predictive of impaired skin integrity?

Answer: prolonged bed rest, pain, warmness, obesity, impaired renal function

What are signs and symptoms of infection?

  1. Symptoms of sepsis
  2. Wound purulence
  3. Altered mental status
  4. Increased white blood cells
  5. All of the above

What medications should be avoided in clients with impaired skin integrity?

  1. Transdermal patches
  2. Topical agents
  3. Intramuscular route
  4. All of the above

How often and how long should antiembolism stockings be removed on a daily basis?

  1. antiembolism stockings should never be removed
  2. 30-60 minutes at least twice a day
  3. 30 minutes once a day
  4. On for 12hrs, off for 12 hours

List at least 3 tips for preventing impaired skin integrity

  1. Changing bed positions often
  2. Alternating pressure/egg-crate mattress, pillows, sheepskin elbow/ heel
  3. Ensuring proper nutrition and hydration
  4. Massaging areas of impaired circulation.
  5. Tools, such as foam blocks or pillows to help elevate extremities
  6. Using bed cradle or footboard to relieve pressure from bed linens
  7. Wearing comfortable shoes/slippers

References:

  1. Doenges, Marilynn E., et al. Nursing Care Plans: Guidelines for Individualizing Client Care. F.A. Davis, 2006.
  2. Haugen, Nancy, et al. Ulrich & Canale’s Nursing Care Planning Guides: Prioritization, Delegation, and Critical Reasoning. Elsevier, 2020.