Nursing care plans:
These are the important elements needed to make a nursing care plan for impaired skin integrity. This nursing care plan contains the basic elements that defines this Nanda nursing diagnosis and the nursing interventions that could be taken as a nurse to make a nursing care plan for a patient with this nursing diagnosis.
Nursing care plan for Impaired skin integrity
Impaired skin integrity: breakdown in skin primarily due to impaired blood supply as a result of prolonged pressure on the tissue. Skin integrity may also be broken as a result of shearing or friction injury. The epidermis is not intact and layers below the skin like the dermis and bone may be visible.
NANDA-I Definition for Impaired skin integrity :
Altered epidermis and/or dermis.
1) Visible breakdown of skin,
2) exposure of dermal tissue or bone
3) denuded skin that may be accompanied by erythema, edema and discharge
4) the skin breakdown may vary in size
5) the adjacent skin will be fragile and edematous
6) depth of the tissue breakdown not fully assessed visually
7) discharge may vary from serous fluid to foul smelling, if there is an infection.
Related Factors (Impaired skin integrity related to):
1. Functional: Immobility is the primary cause. The constant pressure on bony prominences eventually leads to breakdown of skin.
2. Psychological: Client may have mental illness, be delirious and may be sedated or restrained for a prolonged time, which can lead to pressure on skin. Inability to sense pressure or pain is a common cause of pressure sores or open wounds.
3. Pharmacological: Use of certain drugs like sedative, neuromuscular blockers can lead to immobility in one position and lead to pressure sore
4. Mechanical: Anything that applies pressure on skin can lead to breakdown. This can be a cast, splint, physical restraints or poor use of an ambulatory device. Prolonged sleeping or sitting in one position is probably the most common cause of skin breakdown. Client may also have severe itching, which can lead to excoriations and breakdown of skin. A stoma may be poorly functioning and lead to leakage of fecal material on skin
5. Physiological: Poor dietary habits; diminished appetite, inadequate dentition; insufficient fluid intake; and dehydration can prevent wounds from healing
1. Improved appetite and nutrition
2. Turn patient every few hours to prevent constant pressure
3. Healing of skin
4. Absence of inflammation such as redness, swelling and edema
5. Properly functioning stoma
6. Adequate hydration
7. Regaining mobility
Nursing interventions and rationale for each intervention
1. Assess client’s risk of skin breakdown on admission using the available risk assessment tools like the Braden and Knoll assessment scale.
2. Physically examine the skin. Assess the high-risk areas like bony prominences (elbows, sacrum, heels). The skin should be examined for redness, pallor, edema and open sore. Photos should be obtained to prevent potential litigation.
3. If skin impairment is present, it must be staged.
4. Monitor for signs of infection like pain, fever, foul discharge, redness or pus collection .
Measures to prevent skin breakdown
1. Unless contraindicated, the client must be turned at a minimum of 2-3 hours. Prolonged pressure on bony prominences compromises blood flow, leading to skin ischemia.
2. The client must be positioned so that the skin is not exposed to constant pressure all the time. For example, prevent the heels from touching the bed all the time.
3. Use pressure-lowering devices like foam cushions, alternating pressure mattresses, kinetic beds and pillows, when indicated.
4. If skin is redden or swollen, then the area must be massaged every 2 hours to help stimulate blood flow.
5. To lower friction, apply a thin film of cornstarch on the skin to prevent the opposing surfaces from rubbing against each other.
6. When moving client, there should be assistance. A turn-sheet is ideal for moving patient as it prevents friction.
7. Because clients often slide down the bed, this results in increased skin friction and abrasion injury. This can be prevented by placing the knees slightly higher then the head of the bed. One may even place pillow under the knees to prevent sliding downwards.
8. If patient is mentally alert and compliant, he or she should be asked to shift weight every 30-45 minutes.
9. The skin must be kept clean at all times.
10. After bathing or showering the skin must be thoroughly dried. Skin fold areas like the armpit, groin, buttocks, perineum and breast must be thoroughly inspected and patted dry. Rubbing of skin is not recommend as this may lead the fragile skin to breakdown.
11. All bed sheets and other linen must be wrinkle free and dry.
12. If patient uses an ambulatory device, it must be used properly to prevent skin trauma.
Any restraints, casts or braces must be applied properly and rechecked to ensure that they are not causing any type of friction burn.
13. If client has a pressure sore or open wound in the pelvis area, the skin must be protected from feces and urine. Barrier creams should be applied to the perineal area to prevent contamination of the skin with body waste products.
14. Change incontinence pad as soon as possible after client has voided or defecated
15. When possible expose the skin to air
16. General measures to prevent skin breakdown include: 1) encourage client to drink ample water unless contraindicated 2) use a bland non-fragrant soap while showering 3) liberally use a moisturizer 4) keep nails trimmed and short 5) apply mittens if client is prone to scratching and 6) change ostomy appliance when there is a leak.
17. In areas of the body where the skin is thin and prone to breakdown, one should apple a protective dressing. These areas include the heels, coccyx and elbows.
18. The nutritional status of the patient should be assessed on a regular basis.
19. If there is edema in the dependent areas of the body the client should be 1) assisted with some type of motion exercise and 2) the extremity should be elevated, whenever possible.
20. Get client out of bed when possible.
21. Encourage physical activity as permitted
22. Teach client important of skin integrity
23. Implement a written skin protection plan so that all nurses can follow.
1. If skin integrity is compromised, the healthcare provider – i.e. wound care specialist or physician must be promptly notified.
2. A dietitian consult may help with nutrition.
3. If stool leakage is an issue, a surgeon should be consulted.
4. If the stoma is leaking, consult with a stoma nurse.