Nursing Diagnosis Impaired Skin integrity
Altered epidermis and/or dermis: Invasion of body structures, destruction of skin layers (dermis), and disruption of skin surface (epidermis).
Hyperthermia, hypothermia, chemical substance, mechanical factors (e.g. friction, shearing forces, pressure, restraint), physical immobilization, humidity, extremes in age, moisture, radiation, medications
Altered metabolic state, altered nutritional state (e.g. obesity, emaciation), altered circulation, altered sensation, altered pigmentation, skeletal prominence, developmental factors, immunological deficit, alterations in skin turgor (change in elasticity), altered fluid status.
Suggested Nursing Outcomes
- Tissue Integrity: Skin and Mucous Membranes
- Wound Healing: Primary Intention
- Wound Healing: Secondary Intention
- Regains integrity of skin surface
- Reports any altered sensation or pain at site of skin impairment
- Demonstrates understanding of plan to heal skin and prevent reinjury
- Describes measures to protect and heal the skin and to care for any skin lesion
- Incision Site Care
- Pressure Ulcer Care
- Skin Care: Topical Treatments
- Skin Surveillance Wound Care
Nursing Interventions and Rationales
· Assess site of skin impairment and determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, skin tear)
· Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection.
· Individualize plan according to client's skin condition, needs, and preferences. Avoid harsh cleansing agents, hot water, extreme friction or force, or cleansing too frequently .
· For clients with limited mobility, use a risk-assessment tool to systematically assess immobility-related risk factors.
· Do not position client on site of skin impairment. If consistent with overall client management goals, turn and position client at least every 2 hours
· Evaluate for use of specialty mattresses, beds
· Select a topical treatment that will maintain a moist wound-healing environment and that is balanced with the need to absorb exudates
· Avoid massaging around the site of skin impairment and over bony prominences.
· Assess client's nutritional status
· Prior assessment of wound etiology is critical for proper identification of nursing interventions.
· Systematic inspection can identify impending problems early.
· A validated risk-assessment tool such as the Norton or Braden scale should be used to identify clients at risk for immobility-related skin breakdown.
· Transfer client with care to protect against the adverse effects of external mechanical forces such as pressure, friction, and shear.
· To reduce shear and friction, and use lift devices, pillows, foam wedges, and pressure-reducing devices in the bed.
· Massage may lead to deep-tissue trauma
· Inadequate nutritional intake places individuals at risk for skin breakdown and compromises healing
Home Care Interventions Client and Family Teaching
- Teach skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing
- Teach client to use a topical treatment that is matched to the client, wound, and setting.
- If consistent with overall client management goals, teach how to turn and reposition at least every 2 hours
- Teach client to use pillows, foam wedges, and pressure-reducing devices to prevent pressure injury