Impaired Skin Integrity Nursing Care Plan

Jump to Sections

1. Pathophysiology of Impaired Skin Integrity
2. Signs and Symptoms of Impaired Skin Integrity
3. Nursing Assessment for Impaired Skin Integrity
4. Nursing Interventions for Impaired Skin Integrity
5. Nursing Care Plan Example
6. Impaired Skin Integrity NCLEX Questions

What is Impaired Skin Integrity?

When it comes to ensuring patients’ well-being, nurses play a critical role in recognizing and addressing conditions like impaired skin integrity. Skin, as the body’s largest organ, serves as the first line of defense against pathogens and injury. But when its integrity is compromised by cuts, wounds, or other damages, the risks of infection and complications increase exponentially.

This comprehensive guide will help you in understanding, diagnosing, and managing impaired skin integrity. It’s targeted at nursing students, registered nurses (RNs), healthcare professionals, and anyone preparing for the NCLEX. So really, just nurses of all kinds.

By the end, you’ll feel confident crafting nursing care plans and implementing interventions for this condition.

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.

Causes & Risk Factors

Knowing the causes and risk factors can help prevent skin integrity issues in the first place. A few common culprits include:

Internal Factors

• Nutritional Imbalances (e.g., obesity or malnutrition)
• Fluid Imbalances leading to dry or overly hydrated skin
• Altered Circulation from conditions like diabetes or peripheral artery disease
• Aging Skin that becomes thinner and more fragile with time

External Factors

• Physical Trauma such as cuts, abrasions, and ulcers
• Thermal Factors like burns and frostbite
• Chemical Injuries from harsh products or irritants
• Moisture and Hygiene issues, such as excessive sweating or incontinence

Lifestyle and Behavior Factors

• Smoking, which restricts blood flow to skin
• Poor hygiene practices
• Prolonged immobility, increasing the risk of pressure ulcers

Understanding these risk factors is the first step in prevention and intervention.

Signs and Symptoms of Impaired Skin Integrity

Impaired skin integrity can appear differently depending on its cause and severity. Here are the telltale signs to look for in patients during assessment:

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 Diagnosis for Impaired Skin Integrity

Here are some potential nursing diagnoses when impaired skin integrity is present:

• Risk for Infection related to open wounds
• Pain associated with injured tissue or inflammation

These diagnoses provide a framework for developing targeted care plans to support patient recovery.

Nursing Interventions for Impaired Skin Integrity

Evidence-based nursing interventions play a crucial role in treating impaired skin integrity. Here are the most effective strategies to implement in your care plan:

1. Wound Care Protocols

Follow prescribed wound care guidelines to clean, dress, and protect the injured area. Use advanced dressings that promote healing, like hydrocolloid or antimicrobial bandages.

2. Comfortable Positioning

For patients with limited mobility, reposition them every 2 hours to alleviate pressure. Use pillows or wedges to protect bony prominences.

3. Nutritional and Fluid Support

Encourage high-protein diets and adequate hydration to support tissue repair and promote overall healing.

4. Moisture Management

Maintain dry, clean skin for patients at risk of infection (e.g., those with incontinence or excessive perspiration). Use barrier creams to prevent irritation.

5. Patient Education

Teach patients and caregivers basic wound care, skin hygiene, and prevention strategies, such as daily skin inspections and the use of supportive equipment like foam cushions.

Implementing these interventions can significantly reduce complications and improve outcomes.

Nursing Care Plan for Impaired Skin Integrity

Here’s a sample care plan for a patient diagnosed with stage 2 pressure ulcers on the sacrum:

• Diagnosis: Impaired skin integrity related to immobility as evidenced by redness and a shallow wound.
• Goal: Promote wound healing and prevent additional skin breakdown.

By following a well-structured care plan, nurses can ensure patients receive optimal care and attention.

Potential Complications

Without timely intervention, impaired skin integrity can lead to the following complications:

• Systemic or Localized Infection
• Necrosis
• Delayed Wound Healing

Proactively managing impairments reduces the likelihood of these adverse outcomes.

Prevention Strategies

Prevention is always better than treatment! Nurses can help prevent skin breakdown by advocating the following practices:

• Maintain proper hydration and nutrition.
• Encourage patients to follow daily skin hygiene routines.
• Educate caregivers about repositioning techniques and pressure management.
• Avoid known risk factors, such as smoking or poorly fitted shoes.

Additional Resources

For further guidance, check out these helpful tools and references:

• Braden Scale Assessment Guide
• Online wound care training programs (link to reputable resources)

Nursing Care Plan Resources

• Nursing Diagnosis
• Nursing Interventions
• Nursing Care Plan Template
• Nursing Process
• ADPIE

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?

1. Symptoms of sepsis
2. Wound purulence
3. Altered mental status
4. Increased white blood cells
5. All of the above

What medications should be avoided in patients with impaired skin integrity?

1. Transdermal patches
2. Topical agents
3. Intramuscular route
4. All of the above

Final Thoughts on Impaired Skin Integrity

Impaired skin integrity is a common issue faced by healthcare providers, but with effective assessment, timely interventions, and thorough prevention practices, it can be managed successfully. Nurses play a pivotal role in protecting this essential organ from harm and optimizing patient outcomes.

For nursing students preparing for exams or healthcare professionals seeking to refine their skills, applying these principles will not only help patients but also boost your confidence as a competent caregiver.

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.