Impaired Skin Integrity Care Plan
Below are significant elements required for the impaired skin integrity care plan. This planincludes general elements that help to define the Nanda diagnosis and the intervention of a nurse. When an impaired skin integrity nursing diagnosis is made, an accurate care plan is needed.
Nursing Care Plan forImpaired Skin Integrity
First of all, it is vital to explain the impaired skin integrity definition. So, impaired skin integrity refers to the breakdown in skin, which occurs because of impaired blood supply due to the prolonged pressure on skin or tissue. The integrity of skin may break because friction or shearing. When the epidermis is not healthy, the layers located below the skin become visible.
NANDA-I Impaired skin integrity meaning: Changes in dermis and/or epidermis.
Characteristics that define the impaired skin integrity:
- Visible skin breakdown,
- Exposure of bone or dermis,
- Bare skin accompanied by edema, erythema, and/or discharge,
- The breakdown of skin may have different sizes,
- The adjoining skin becomes edematous, sensitive and fragile
- The depth of skin breakdown cannot be fully estimated from the first sight
- The discharge variesin relation to the infection. In case of infection, foul smelling is present.
Impaired Skin Integrity Factors
- Functional factor: The primary cause is immobility. Continuous pressure on bony convexities results in skin breakdown.
- Psychological factor: Patient may suffer from some mental disorder. He/she may have a delirium and can be restrained or sedated for a long period of time. It can result on skin pressure. Being unable to feel pain or pressure is the major reason of open wounds as well as pressure sores.
- Pharmacological factor: using such medicine as sedative drugs neuromuscular blockers may result in immobility and then cause pressure sore
- Mechanical factor: Any object that can cause pressure may result in skin breakdown. It can be splint, cast, physical restraints or inappropriate use of any type of devices. Sitting or sleeping in one without changing the position for a long period of time is considered to be the most common reason of skin breakdown. Patient may suffer from itching, which in its turn leads to skin breakdown and excoriations. Stomata may not function well and cause fecal material leakage on skin.
- Physiological factor:poor diet; absence of appetite; poor dentition; inadequate intake of fluid can be the reasons of wounds failure to heal.
Outcomes of Nursing
- Improved nutrition and good appetite.
- In order to avoid continuous pressure, a patient should be turned every few hours.
- Skin healing.
- Inflammation absence, like swelling, redness and edema.
- Correct stomata functioning.
- Proper hydration.
- Patient regains mobility.
Rationale for Nursing Intervention
- Estimate patient's risks of skin breakdown applying valid risk assessment instrument such as Braden and Knoll assessment scale.
- Conduct a physical skin examination. Evaluate the areas of high risks, such as bony eminences (heels, sacrum and elbows). Patient's skin has to be checked for pallor, redness, open sore and edema. In order to prevent any potential litigation, it is recommended to obtain photos.
- When a patient is diagnosed with skin impairment is present, stage it and create an effective impaired skin integrity care plan.
- Any infection signs should be monitored. They include fever, pain, foul discharge, pus collection or redness.
How to Prevent the Breakdown of Skin?
- If there is no contraindication, the patient should be tuned every few hours. Continuous pressure on bony eminences makes the blood flow complicated, which can result in skin ischemia.
- The patient should be positioned in such a way so that his/her skin does not feel any pressure. For instance, the heels can be prevented from touching the bed.
- Devices that lower the pressure should be used. For example, kinetic pillows and beds, foam cushions, mattresses that change pressure.
- When skin is swollen or redden,the detected area should be massaged every few hours. It will assist in increasing the blood flow.
- In order to reduce the friction, use a cornstarch film so that the opposing surfaces do not rub against each other.
- It is required to have assistance while moving the patient. A turn sheet is perfect during this process since it does not allow friction.
- Patients can slide down the beds and it causes skin friction and any other skin injuries. It is possible to prevent this by located the patient's knees higher than the bed heading. The easiest way to prevent sliding down the bed is by putting the pillow under the patient's knees.
- When a patient is compliant and alert mentally, he/she should be informed about shifting the weight every half an hour.
- It is important to maintain skin cleanliness all the time.
- It is vital to make sure the skin is dried after showering or bathing. The areas where skin is folded, such as groin, armpit, perineum, buttocks and breast, must be checked and dried as well. It is not recommendedto rub the skin. It can cause breakdown of fragile skin.
- Make sure the linen and bed sheets are dry and do not wrinkle.
- A patient should use an ambulatory device properly in order to prevent skin injury. Any braces, restraints or casts should be used in a proper manner and double checked to make sure that they are not the reason of friction.
- When a patient has an open wound or a pressure sore in the area of pelvis, it is important to protect the skin from urine and feces. Apply a barrier cream to the pelvis area in order to avoid skin contamination with any products.
- The incontinence pad should be changed right after the patient has defecated or voided
- Patient's skin should be exposed to fresh air every time an opportunity arises
- Nursing care plan for impaired skin integrity should include the following measure: 1) encourage patient to drink a lot of fluid unless it is forbidden by the doctor; 2) while taking a bath or showering, a patient should use a non-fragrant soap; 3) using a moisturizer should be encouraged as well; 4) nails should be trimmed and remain short; 5) when a patient is prone to scratch him/herself, mittens should be used; 6) when there is a leak, ostomy appliance should be replaced.
- A protective dressing should be used in body areas where the skin is thin and can break easily. Such areas are as following: coccyx, heels and elbows.
- An effective impaired skin integrity care plan should include the assessment of patient's nutrition status.
- Patient should perform motion exercise.
- Patient should not stay in bed all the time.
- Physical activity should be encouraged.
- Skin integrityshould be explained to the patient.
- Every nurse should follow the care plan.
- When skin integrity is compromised, a physician should be informed about it immediately.
- A dietitian should help with nutrition.
- A surgeon should be informed about stool leakage.
- A stoma nurse should give recommendations in case of stoma leakage.