Impaired Skin Integrity refers to damage to the epidermis and/or dermis, which compromises the skin’s ability to protect against external harm. This condition is commonly seen in patients who are bedridden, have chronic illnesses, or are exposed to environmental hazards.
Timely and effective nursing care is crucial to prevent complications such as infection, delayed healing, and scarring.
Definition of Impaired Skin Integrity
The NANDA-I defines Impaired Skin Integrity as “altered epidermis and/or dermis.” This diagnosis is used when there is evidence of damage to the skin tissue.
Causes can range from pressure ulcers and wounds to burns and other trauma.
Causes of Impaired Skin Integrity
Common factors contributing to Impaired Skin Integrity include:
- Prolonged pressure (e.g., pressure ulcers)
- Immobility
- Inadequate nutrition or hydration
- Advanced age
- Chronic diseases (e.g., diabetes mellitus)
- Incontinence
- Excessive moisture or dryness
- Surgical incisions
- Burns and trauma
Assessment and Clinical Manifestations
The clinical presentation of Impaired Skin Integrity varies based on its cause. Nurses must assess:
- Skin color, texture, temperature, and moisture levels
- Presence of wounds, ulcers, or lesions
- Signs of infection (e.g., redness, swelling, pus)
- Pain or discomfort
- Risk factors (immobility, malnutrition, etc.)
The Braden Scale is a useful tool for assessing patients at risk of developing skin integrity issues. It evaluates six factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
Nursing Interventions for Impaired Skin Integrity
When addressing Impaired Skin Integrity, nurses must focus on both preventive measures and active wound management. Key interventions include:
- Regular skin assessment and monitoring
- Repositioning the patient to relieve pressure points
- Maintaining appropriate skin moisture levels
- Using pressure-relieving devices i.e. special mattresses or cushions
- Ensure adequate nutrition & hydration to assist with skin healing
- Cleaning wound(s) properly & applying appropriate dressings
- Educate patients and families on skin care
Nursing Care Plans for Impaired Skin Integrity
Below are five detailed nursing care plans, each addressing a different aspect of Impaired Skin Integrity.
Nursing Care Plan 1: Pressure Ulcer Prevention
Nursing Diagnosis Statement:
Impaired Skin Integrity related to immobility and pressure over bony prominences as evidenced by Stage 1 pressure ulcer on the sacral area.
Related Factors/Causes:
- Immobility due to prolonged bedrest
- Inadequate turning and repositioning
- Poor circulation
Nursing Interventions and Rationales:
- Turn and reposition patient every 2 hours: This intervention reduces prolonged pressure on bony prominences, promoting better circulation and preventing skin breakdown.
- Use a pressure-relieving mattress or cushion: Specialized surfaces can distribute pressure more evenly and prevent ulcers from worsening.
- Monitor skin daily for any redness or discoloration: Early identification of pressure areas allows for timely intervention.
- Ensure adequate nutrition with protein and vitamins: Proper nutrition supports tissue repair and enhances immune function, reducing the risk of infection.
Desired Outcomes:
- The patient’s pressure ulcer will not progress to Stage 2.
- The patient will demonstrate intact skin with no signs of further breakdown.
Nursing Care Plan 2: Wound Healing Management
Nursing Diagnosis Statement:
Impaired Skin Integrity related to surgical incision as evidenced by redness and delayed wound healing.
Related Factors/Causes:
- Recent surgery
- Poor wound care
- Inadequate nutritional intake
Nursing Interventions and Rationales:
- Perform sterile dressing changes as prescribed: Maintaining a sterile field during wound care reduces the risk of infection.
- Monitor wound site for signs of infection (redness, swelling, drainage): Early detection of infection allows for prompt treatment and prevents further complications.
- Encourage intake of high-protein foods and fluids: Proteins are essential for wound healing and tissue regeneration.
- Teach patient proper wound care techniques at home: Educating the patient can promote autonomy and reduce the risk of infection after discharge.
Desired Outcomes:
- The surgical wound will show signs of healing within two weeks.
- The patient will demonstrate the ability to perform wound care independently.
Nursing Care Plan 3: Burn Care
Nursing Diagnosis Statement:
Impaired Skin Integrity related to third-degree burn as evidenced by tissue necrosis and exudate formation.
Related Factors/Causes:
- Thermal injury
- Poor circulation to the affected area
- High risk of infection
Nursing Interventions and Rationales:
- Cleanse the burn wound with antiseptic solution as ordered: Reducing bacterial load prevents infection and promotes healing.
- Apply prescribed topical antibiotics and sterile dressings: Topical treatments minimize bacterial colonization and protect the wound from contaminants.
- Assess for signs of infection, including increased pain or swelling: Early detection of infection is critical in preventing sepsis.
- Encourage a high-calorie, high-protein diet to support tissue repair: Burn patients have increased metabolic needs that must be met for proper healing.
Desired Outcomes:
- The burn wound will remain free of infection.
- The patient will show progressive healing of the burn site.
Nursing Care Plan 4: Incontinence-Associated Dermatitis
Nursing Diagnosis Statement:
Impaired Skin Integrity related to prolonged exposure to moisture as evidenced by maceration and excoriation in the perineal area.
Related Factors/Causes:
- Incontinence of urine and/or feces
- Poor skin hygiene
- Inadequate moisture barrier protection
Nursing Interventions and Rationales:
- Perform perineal care after each episode of incontinence using gentle cleansers: Proper cleaning prevents further skin breakdown.
- Apply moisture barrier creams to affected areas: These creams protect the skin from further irritation by creating a barrier against urine and feces.
- Reposition patient regularly to reduce prolonged moisture exposure: Frequent repositioning allows the skin to dry and heal.
- Monitor skin for signs of fungal infection (e.g., redness, itching): Early detection of fungal infection allows for prompt treatment, preventing further damage.
Desired Outcomes:
- The patient will demonstrate improved skin condition in the perineal area within one week.
- The skin will remain free of infection.
Nursing Care Plan 5: Diabetic Ulcer Management
Nursing Diagnosis Statement:
Impaired Skin Integrity related to diabetic neuropathy as evidenced by the presence of an ulcer on the foot.
Related Factors/Causes:
- Diabetic neuropathy
- Poor circulation
- Inadequate glycemic control
Nursing Interventions and Rationales:
- Assess blood glucose levels regularly: Maintaining blood glucose within normal limits reduces the risk of delayed wound healing.
- Perform daily foot assessments for redness, swelling, or open sores: Early identification of skin issues in diabetic patients is essential for preventing complications.
- Encourage patient to wear well-fitting shoes to prevent pressure ulcers: Proper footwear can prevent trauma to the feet.
- Collaborate with a podiatrist for specialized foot care: Ongoing foot care is vital for preventing complications such as amputation.
Desired Outcomes:
- The diabetic ulcer will show signs of healing within two weeks.
- The patient will maintain stable blood glucose levels to promote optimal wound healing.
Reviewed References
- Berman, A., Snyder, S., & Frandsen, G. (2019). Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (11th ed.). Pearson.
- Hinkle, J. L., & Cheever, K. H. (2021). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (15th ed.). Wolters Kluwer.
- NANDA International. (2021). NANDA International Nursing Diagnoses: Definitions and Classification 2021-2023 (12th ed.). Thieme Medical Publishers.
