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- Pathophysiology of Impaired Skin Integrity
- Signs and Symptoms of Impaired Skin Integrity
- Nursing Assessment for Impaired Skin Integrity
- Nursing Interventions for Impaired Skin Integrity
- Impaired Skin Integrity NCLEX Questions
Pathophysiology of Impaired Skin Integrity
An impaired skin integrity nursing diagnosis and early recognition allow for prompt intervention. Implementing the risk for impaired skin integrity care plan can help prevent further complications, including discomfort and infections.
Risk factors (causes)
- Physical immbobilization/bedrest
- Edema
- Decreased tissue perfusion
- Poor nutritional state
- Impaired circulation
- Disease processes such as diabetes, autoimmune
- Moisture
- Shearing/Friction
- Obesity
Signs and Symptoms of Impaired Skin Integrity
Subjective (patient may report)
- verbal report of pain
- altered sensation at the site if tissue impairment
Objective (Nurse assesses)
- Skin color changes
- Skin redness
- Warmth of skin
- Skin areas demonstrating impairment
- Areas of decreased sensation
- Albumin
- Protein
Expected outcomes
- Patient will maintain intact skin integrity
- Patient will have timely healing of wounds without complications
- Patient will verbalize preventative measures to decrease pressure injury
- Patient will demonstrates behaviors/techniques to prevent skin breakdown
Nursing Assessment for Impaired Skin Integrity
A thorough skin assessment should include bony prominences, dependent areas, and affected extremities for pallor, redness, and breakdown. Collect patient history, including risk factors and symptoms (objective and subjective data).
Braden skin scale
The Braden scale consists of six subscales and ranges from 6-23. The lower the score, the higher the risk for pressure ulcer development.
Cardiac Assessment
- Abnormal heart
- Changes in blood pressure
Respiratory Assessment
- Changes in breathing
- Decreased oxygen saturation
Nutritional Assessment
- Decreased intake
- Poor protein intake
Neurologic/Sensory Assessment
- Pain
- Loss of sensation
- Confusion (risk of infection)
Visual appearance/labs
- Pallor
- Redness
- Breakdown of skin covering bony prominences
- Pruritic areas
- Perineum
Nursing Interventions for Impaired Skin Integrity
Perform:
- Ongoing skin inspection, noting skeletal prominences, areas of altered circulation, pigmentation, obesity, and emaciation
- Checks for edema
- Removal of antiembolism stockings for 30-60 minutes at least twice a day
Provide:
- Frequent skin care, minimize contact with moisture/excretions
- 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 mattresses, pillows, sheepskin elbow/ heel protectors such as gel or foam cushions
- Reduce pressure on the skin, improve circulation
- Assist patient with turning every two 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 to pressure on skin on feet
- Excessive dryness or moisture as they can damage the skin and hasten a breakdown
Patient Education:
- Pressure management to prevent ulceration
- Check for a fit of shoes and slippers, and change as needed
- Encourage smoking cessation
- Educate about tips to conserve energy
Documentation and Evaluation
Documentation is vital to safe patient care. The nurse is responsible for photographing and precise terminology to accurately describe a wound. Accurate documentation includes location, type of wound, measurement, color, texture and drainage, and any interventions initiated.
It’s also important to document the patient’s response to the wound and wound care. The evaluation of nursing interventions and patient education are part of the nursing process, which will help the patient to achieve the best outcome possible.
Impaired Skin Integrity NCLEX Questions
Based on the patient’s case, what factors predict impaired skin integrity?
Answer: prolonged bed rest, pain, warmness, obesity, impaired renal function
What are signs and symptoms of infection?
- Symptoms of sepsis
- Wound purulence
- Altered mental status
- Increased white blood cells
- All of the above
What medications should be avoided in patients with impaired skin integrity?
- Transdermal patches
- Topical agents
- Intramuscular route
- All of the above
References:
Doenges, Marilynn E., et al. Nursing Care Plans: Guidelines for Individualizing Client Care. F.A. Davis, 2006.
Haugen, Nancy, et al. Ulrich & Canale’s Nursing Care Planning Guides: Prioritization, Delegation, and Critical Reasoning. Elsevier, 2020.
