The human body has a well-maintained protection system against all external threats. A major part of this system is made up of the skin, the largest organ of the human body. It protects the body from injuries, infections, heat, light, pollutants, etc. When the skin is compromised due to injuries like cuts, rashes, abrasions, the integrity of the skin layer is compromised. This is called having impaired skin integrity.
As aging occurs, the skin layer naturally thins, making the skin more prone to damage. Furthermore, there is also a loss of natural moisturizing factors, like hyaluronic acid, from the skin. This makes the skin more dry, flaky, and susceptible to damage. Therefore, older adults are at a much higher risk for impaired skin integrity.
This is a phenomenon that may be accelerated by certain medications, sun exposure, or genetics. However, poor nutrition, certain diseases, surgical procedures, or immobility (in comatose patients or those with spinal cord injuries) can also contribute to heightened impaired skin integrity.
Signs and Symptoms of impaired tissue integrity
- Affected area suspected of impaired skin integrity may be hot and tender to touch. There may be observations of fever.
- Visible damage to integumentary tissues like the cornea, mucous membranes, subcutaneous skin, etc.
- The area may be inflamed and cause pain to the patient
- Guarding of the affected area, and grimacing on contact with affected area
- Bruising or inflammation of the tissue leading to colour changes (red, purplish, black)
- Swelling around the initial injury, and signs of systemic infection
Rationales and Assessments of Impairment of Tissue Integrity
It is extremely important that nurses have the skills and knowledge when assessing at-risk patients for impaired skin integrity. This may help identify any possible causes or even predict possible episodes. In such cases, training in wound care can help in creating a structured impaired integrity plan. Some of the common assessments are as follows:
- Determine etiology: Prior assessment of the wound helps establish the causative agents behind it. This helps determine a detailed etiology, which is imperative in ascertaining treatment strategies for better outcomes.
- Assess the site of impaired tissue integrity and its condition: The wound area must be inspected for redness, swelling, pallor, etc. This helps confirm an actual nursing diagnosis for impaired skin integrity.
- Assess characteristics of the wound: For gauging the extent of injury, characteristics like the color of the wound, odor, exudation, and pus formation need to be assessed. This step is crucial to rule out infections or the presence of necrotic tissues.
- Assess changes in body temperature: A spike in body temperature is typically a sign of fever – indicating the onset of infection.
- Assess the patient’s level of pain: If the area of the wound is red and inflamed, it will stimulate natural pain responses. However, heightened pain sensations may indicate deeper injuries.
- Monitor site of impaired tissue integrity regularly: A daily observation of redness, swelling, temperature, and other signs of impending infections can help pinpoint significant changes in the state of the wound.
- Monitor the status of the skin around the wound: Any impairments of the skin around the wound need to be monitored regularly to ensure the infection is localized, and does not spread.
- Know signs of itching and scratching: The inflamed condition of the wound may trigger itching sensations. If a patient scratches, they may reopen the healing wound and increase the risk for infection.
- Assess patient’s nutritional status: The nutritional status of a patient holds significant importance in healing impaired skin. Inadequacy in such can slow down the healing process.
- Classify pressure ulcers by assessing the extent of tissue damage: Pressure ulcers may lead to skin ischemia, thus need to be treated according to their severity as soon as possible. By assessing the tissue damage and using scales like Braden scale or Norton scale, risk assessment can be carried out.
- Monitor for proper placement of tubes: External shear or friction can be a source of mechanical damage to the skin. Tubes, masks, catheters, etc. are often associated with this damage.
Developing Nursing Care Plans for Patients with Impaired Skin Integrity
A nursing care plan is a documented process that provides directions on the type of nursing care a patient, family, or community needs. It provides a systematic guide using 6 sequential steps – assessment, diagnosis, expected outcomes, interventions, rationale, and evaluation, through which patient-centric care can be practiced.
Following are some examples of how a nursing care plan can be developed for patients who are at-risk for impaired skin integrity:
Nursing Plan 1 – Pressure ulcers/Bedsores
- Diagnosis: Pressure ulcers causing impaired skin integrity due to immobility as evidenced by the presence of stage 3 pressure ulcers on the sacrum
- Outcome: The bedsore will show optimal healing and development of further bedsores will be prevented.
|Regularly assess the condition of bedsore and measure using the scales||This is done to provide baseline data and track the progress of healing processes. Scales like Braden and Norton can help track this information.|
|Promote regular movement||Active turning and movement can prevent the buildup of pressure and reduce the occurrence of bedsores.|
|Provide appropriate lumbar support||Mattresses and cushions that help spread equal pressure can prevent the flare-up of bedsores.|
Nursing Plan 2 – Impetigo
- Diagnosis: Development of red sores around the wound area in a patient diagnosed with Impetigo, with itching and discharge from the wound.
- Outcome: The patient will be able to restore healthy skin after the treatment regimen.
|Isolation of the patient||Impetigo is highly infectious. The patient would have to be isolated for around 7-10 days while being treated.|
|Administer the prescribed antibiotics and ensure completion of the course||Impetigo is treated by antibiotics that can be given orally or topically. Further infection can re-occur, hence the completion of the regimen is necessary.|
|Educate the caregivers about hygiene and scratching||Scratching worsens Impetigo and aggravates healing wounds. The patients and the caregivers need to be particular about hygiene and scratching to prevent this.|
Nursing Plan 3 – Skin gangrene/Necrotizing Fasciitis
- Diagnosis: Necrotizing fasciitis confirmed by positive biopsy leading to the development of gangrenous skin tissue accompanied by erythema at the infected site.
- Outcome: The patient will experience optimal wound healing while avoiding the spread of this infection.
|Monitor infection and its spread||Necrotizing fasciitis can easily spread if not managed carefully. It needs to be monitored very closely.|
|Administer the antibiotics as prescribed||Treating the bacterial cause behind Necrotizing fasciitis can reduce the gangrenous tissue.|
|Encourage hygiene and skincare||To prevent the spread of the infection and compensate for the loss of protective bacteria due to antibiotics|
Nursing Plan 4 – Diabetes foot
- Diagnosis: Decreased circulation from dorsal arteries in a patient with diabetes which poses risk for impaired skin integrity.
- Outcome: The patient will be able to avoid vascular damage to the limb while waiting for treatment.
|Encourage continuous use of footwear||Diabetic patients often suffer from loss of sensations. This may cause them to not notice any injuries and infections.|
|Assess skin integrity regularly||In cases of interventions and evaluations, baseline data is pertinent in tracking progress.|
|Encourage daily moisturization and prevention of hot water use.||Hot water can cause drying of the skin which may impair the skin integrity further. Moisturization can prevent this.|
Nursing Plan 5 – Edema formation
- Diagnosis: Malnourished patient with Kawasaki disease showing bilateral swelling of feet.
- Outcome: Edema formation will subside with appropriate treatment and skin integrity will not be damaged.
|Assess and scale the level of edema in the feet||Observational data can help evaluate progress.|
|Encourage movement and mobility.||Movement will promote blood circulation and drainage of the built-up fluid from the limbs.|
|Encourage patients to wear dilated clothing||Tight and constrictive clothing can further aggravate skin irritation and also prevent fluid drainage.|
Holistic nursing care involves treating the patients and protecting them from potential threats. Making an appropriate impaired skin integrity nursing diagnosis is a part of the daily evaluation of healthcare staff and is necessary to protect the integrity of the skin.
Therefore, it is important that nurses have the appropriate skills and tools required for the same. Identifying the risk factors and preventing poor skin integrity early on can foster positive outcomes.
1) What are the four types of nursing diagnosis?
The four types of nursing diagnosis are: Problem-focused, Risk-based, Health promotion based, and Syndrome diagnosis. If we consider a symptom such as ineffective breathing patterns, the diagnoses would be Decreased lung expansion, Pneumonia, Smoking, and Chronic Pain Syndrome, respectively.
2) How do you document skin integrity?
Skin integrity data is very important in the evaluation of outcomes and treatments. The assessments should include information about the skin’s color, temperature, texture, moisture, integrity and also document any open or healing wounds and their locations.
3) How do you prevent skin breakdown?
Typically, strategies that aim to prevent skin breakdown focus on
- Patient repositioning
- Proper hygiene and regular cleaning
- Balanced nutritional intake
- Regular assessments and documentation
- Education of caregivers
4) What are the three parts of the nursing diagnosis quizlet?
The three parts of the Quizlet include: The patient’s need (NANDA-I nursing diagnostic label), Etiology of the condition, and Signs and symptoms
5) What is NANDA approved nursing diagnosis?
A NANDA-approved nursing diagnosis is based on standard terminology developed by the North American Nursing Diagnosis Association. For example, an ineffective airway clearance diagnosis is related to retained secretions and cough observations.