Nursing Care Plans for Impaired Skin Integrity – Best Nursing Care Plans(2022)

This article discusses Nursing Care Plans for Impaired Skin Integrity plus its causes, symptoms, preventions, treatments and interventions.

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Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor in case you’re looking for medical advice.

Introduction

The skin is the largest organ in the human body and is a protective barrier. It protects the body from heat, light, injury, and infection. Skin integrity relates to skin health. A skin integrity problem might indicate the skin is damaged, exposed to injury, or inefficient to repair and recover normally. The key marker of quality care is the maintenance of skin integrity and preventing pressure ulcers. With this, the nurse must identify at-risk individuals and the myriad factors that place patients at risk for skin damage.

Pressure, shear, and friction from immobility put an individual at risk for altered skin integrity. Patients who are overweight, paralyzed, with spinal cord injuries, those who are bedridden and confined to wheelchairs, and those with edema are also at the highest risk for altered skin integrity. Other factors that hasten skin breakdown include age, the normal loss of elasticity, inadequate nutrition, environmental moisture, and vascular insufficiency. Special beds, mattresses, and other useful devices provide pressure relief and pressure redistribution.

Nurses should have the skills and knowledge to deal with patients at risk for impaired skin integrity because overall skin assessment is not a one-time event confined to admission. It demands to be repeated regularly to ascertain whether any alterations in skin condition have transpired. Training in wound management can help in creating impaired skin integrity care plans.

Nursing Care Plans for Impaired Skin Integrity – Causes of Impaired Skin Integrity

Internal:

• Poor nutritional state (obesity, emaciation, dehydration)
• Edema
• Impaired circulation
• Neuropathy
• Disease processes (diabetes, autoimmune disorders)

External:

• Hyperthermia
• Hypothermia
• Radiation
• Chemicals
• Extremes in age
• Physical immobilization/bedrest
• Paralysis
• Surgery
• Cognitive impairment
• Moisture/secretions
• Shearing/friction/pressure

Nursing Care Plans for Impaired Skin Integrity – Signs and Symptoms Impaired Skin Integrity

• Pain
• Itching
• Numbness to affected and surrounding skin

Nursing Assessment for Impaired Skin Integrity

The following nursing assessments are done for the nursing diagnosis risk for impaired skin integrity that you can use in your “assessment column” in developing your impaired skin integrity care plan.

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Assessment	Rationale
Assess the overall condition of the skin.	Assessment of the skin condition provides baseline data for possible interventions for the nursing diagnosis Risk for Impaired Skin Integrity.   Normal skin condition differs among individuals. Healthy skin should have good turgor (an indication of moisture), feel warm and dry to the touch, be free from impairment (cuts, wounds, abrasions, excoriation, outbreaks, and rashes), and have quick capillary refill (less than 6 seconds). Patients with advanced age are at high-risk risk for skin impairment because the skin is less elastic, has less moisture, and has thinning of the epidermis.
Check on bony prominences such as the sacrum, trochanters, scapulae, elbows, heels, inner and outer malleolus, inner and outer knees, back of the head).	Specific areas where the skin is stretched tautly are at higher risk for the breakdown because the possibility of ischemia to the skin is high as a result of compression of skin capillaries between a hard surface (e.g., mattress, chair, or table) and the bone. For lightly pigmented skin, pressure areas appear to be red. These areas appear to be red, blue, or purple hue spots for darker skin tones.
Evaluate the patient’s awareness of the sensation of pressure.	Usually, individuals change position off pressure areas every few minutes; these occur automatically, even during sleep. Patients who are unaware of sensation tend to do nothing, thus resulting in prolonged pressure on skin capillaries and eventually in skin ischemia.
Use an objective tool for pressure ulcer risk assessment.	These are validated tools for risk assessment.   Acute care: Assessment should be every 24 to 48 hours or sooner if the patient’s condition changes. Long-term care: Assess on admission, weekly for 4 weeks, and then quarterly and whenever resident’s condition changes.
Braden Scale	This is a widely used scale. It consists of six subscales: sensory, perception, moisture, activity and mobility, nutrition, and friction/shear.
Norton scale	This system remains popular due to its ease of use. It includes the assessment of physical condition, mental condition, activity, mobility, and incontinence.
Evaluate the patient’s strength to move (e.g., shift weight while sitting, turn over in bed, move from bed to chair).	The greatest risk factor in skin breakdown is immobility.
Assess patient’s nutritional status, including weight, weight loss, and serum albumin levels.	An albumin level less than 2.5 g/dL is a grave sign, indicating severe protein depletion and a high risk of skin breakdown.
Assess for fecal/urinary incontinence.	Stool may contain enzymes that cause skin breakdown. The urea in urine turns into ammonia within minutes and is caustic to the skin. Use of diapers and incontinence pads hastens skin breakdown.
Assess for history or presence of AIDS or other immunological problems.	Skin lesions or Kaposi’s sarcoma is an early manifestation of diseases related to HIV.
Assess for a history of radiation therapy.	Radiated skin becomes thin and friable, may have less blood supply, and is at higher risk for breakdown.
Assess for edema.	Skin tightened tautly over edematous tissue is at risk for impairment.
Assess the amount of shear (pressure exerted laterally) and friction (rubbing) on the patient’s skin.	A typical cause of shear is elevating the head of the patient’s bed: the body’s weight is displaced downward onto the patient’s sacrum. Typical causes of friction include the patient rubbing heels or elbows against bed linen and moving the patient up in bed without the use of a lift sheet.
Assess the surface that the patient consumes most of his or her time on (e.g., mattress for a bedridden patient, cushion for people in wheelchairs).	Patients who spend the majority of their time on one surface require a pressure reduction or pressure relief device to distribute pressure more evenly and reduce the risk for breakdown.
Assess for environmental moisture (e.g., wound drainage, high humidity).	Moisture may contribute to skin maceration.
Assess the skin for:
Dermatitis or exposure to chemical irritants	These conditions can cause inflammation, resulting in redness and itching, and may cause blisters.
Pruritus (itching) or mechanical trauma	Itching or mechanical traumas can result in disruptions to skin integrity and reduce its barrier function.
Long-term steroid use.	Long-term steroid use may leave skin papery thin, and prone to injury.
Reassess the skin regularly and whenever the patient’s condition or treatment plan results in an increased number of risk factors.	The incidence and onset of skin breakdown are directly related to the number of risk factors present.

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Nursing Care Plans for Impaired Skin Integrity Based on Diagnosis

Nursing Care Plans for Impaired Skin Integrity: Care Plan 1 – Diagnosis: Kawasaki Disease

Impaired skin integrity related to edema formation secondary to Kawasaki disease. Evidenced by bilateral swelling of the legs and feet and a small cut on the left ankle.

Desired Outcome

A patient will have healed left ankle wound, and further skin damage will be prevented.

Interventions	Rationales
Assess the skin for its integrity, color, moisture, and texture.	Kawasaki disease affects the skin and can cause erythematous rashes and edema, particularly on the hands, arms, legs, and feet.
Assess the level of edema on the legs and cut on the ankle	Baseline data will help in the evaluation of progress after interventions are made.
Encourage the patient to elevate legs and avoid putting them in a dependent position for a long period of time.	Putting legs in a dependent position will worsen leg edema.
Encourage mobility	Physical activity helps promote circulation and fluid drainage.
Dress wounds as needed, avoiding tight, constricting, and sticky dressings.	As needed, the wound will need to be dressed and cleaned. Sticky dressings may be challenging to remove and cause further damage.
Encourage patient to avoid wearing constricting clothing	Tight clothing can further irritate skin damage and rashes.
Encourage proper hydration	Dehydration can cause further skin injury due to skin dryness.

Nursing Care Plans for Impaired Skin Integrity: Care Plan 2 – Diagnosis: Diabetes

Risk for impaired skin integrity due to decreased circulation from popliteal artery obstruction secondary to Type 2 diabetes

Desired Outcome

The patient’s foot will remain intact while waiting for vascular treatment.

Interventions	Rationales
Assess skin integrity, taking note of color, moisture, texture, and pulses regularly.	Baseline data is needed for prompt evaluation after interventions are made. It will also help in the regular assessment of the progress of nursing care.
Encourage the use of footwear at all times.	Diabetes can affect sensation in the extremities. Patients may not notice the injury.
Encourage daily moisturization of feet.	Moisturizing feet every day provides an opportunity to assess the integrity of the feet daily. Also, moisturizing the feet helps keep their intact skin integrity.
Check water temperature when washing feet.	Patients may not notice if the water is too hot due to reduced sensation.
Encourage patient to maintain short toenails	Long toenails can cause damage to the skin.
Discuss smoking cessation programs if the patient is a smoker	Vascular problems are worsened by smoking, also, the success of vascular treatments such as angioplasty can be affected if the patient will not stop smoking after having it.
Monitor and maintain a normal blood sugar level Hyperglycemia and hypoglycemia can both affect vascular health.
Review medications	Some medications used in type 2 diabetes can predispose patients to foot problems, though research is still inconclusive.
Prepare patient for vascular treatment.	Depending on the medical plan, the patient may have to undergo surgical treatment.

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Nursing Care Plans for Impaired Skin Integrity: Care Plan 3 – Diagnosis: Pressure ulcers / Bedsores

Impaired skin integrity secondary to decreased mobility. Evidenced by the presence of a stage 2 pressure ulcer on the sacrum.

Desired Outcome

The patient’s bedsore will show optimal healing, and further bedsores will be prevented.

Interventions	Rationales
Assess and record the integrity of the skin	To provide baseline data to assess care.
Regularly assess the condition of bedsoreTo regularly assess the progress of healingPromote regular turning or position changeTo prevent prolonged pressure on one area of the bodyAssess the ability of the patient to mobilizeTo assess the extent of physical activities that the patient can do.
Provide appropriate mattress and cushion	Pressure release mattresses and cushions are helpful to prevent sores from occurring, and they help spread equal pressure to the body when sitting and lying down.
Clean and dress bedsore as needed	Sacral sores are prone to infection due to their location.
Clean or assist the patient in cleaning himself after opening bowels	due to the location of bedsore, it can easily be reached by stool when bowels are opened.
Refer to physiotherapy	Physiotherapists can help assess mobility and advise on positioning and mobility aids.
Change sheets regularly and avoid folds and creases.	Creases on sheets can cause pressure on the skin.
Provide pain relief as needed	Bedsores can be uncomfortable for patients. Providing pain relief will help encourage patients to mobilize and change positions.

Nursing Care Plans for Impaired Skin Integrity: Care Plan 4 – Diagnosis: Impetigo

Impaired Skin Integrity related to infection of the skin secondary to impetigo.

Evidenced by:

• Red sores around the area of the nose and mouth
• Discharge from the sores for a couple of days
• Development of yellowish-brown crust,
• Mild itching
• Pain
• Soreness

Desired Outcome

The patient will re-establish healthy skin integrity by following a treatment regimen for impetigo.

Intervention	Rationale
Assess the patient’s skin on his/her whole body.	To determine the severity of impetigo and any affected areas that require special attention or wound care.
Isolate the patient in his/her room, at home, ideally for 10 days.	Impetigo is an infectious/ communicable skin disease. The patient needs to be isolated ideally for 7 to 10 days after starting treatment.
The affected area should be soaked first in warm water to remove the scabs, wet compresses may also be used. This is followed by the application of the prescribed antibiotic cream or ointment directly to the affected areas.	Removal of scabs prior to applying the topical antibiotic promotes good absorption of the medication.
Administer antibiotics as prescribed. Ensure that the patient finishes the course of antibiotics prescribed by the physician.	Impetigo is generally treated through the use of antibiotic therapy. If the infection is mild and has not spread to other areas of the body, the sores can be treated through the use of over-the-counter antibiotic cream containing bacitracin as a home remedy. Application of non-stick bandages over the affected areas can also help prevent the spread of sores and further infection. The doctor may also prescribe oral antibiotic drugs in patients who have a lot of impetigo sores. Even if the symptoms have already improved and healing is evident, it is still essential to finish the course of antibiotic therapy to prevent recurrence of infection and antibiotic resistance.
Educate the patient and caregiver about proper wound hygiene by washing the sores with soap and water. Advise the patient and caregiver to prevent scratching the affected areas.	It is important to maintain the cleanliness of the affected areas by washing with mild soap and water. The sores may cause mild itching, but it is advisable to prevent the child from scratching the affected areas to prevent the worsening of the infection.
Teaching the patient/ caregiver the proper application of non-stick bandages over the affected areas can also help prevent the spread of sores and further infection.	Proper application of non-stick bandages over the affected areas can also help prevent the spread of sores and further infection.

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Nursing Care Plans for Impaired Skin Integrity: Care Plan 5 – Diagnosis: Necrotizing Fasciitis/ Skin Gangrene

Impaired Skin Integrity related to the infective process of necrotizing fasciitis.

Evidenced by:

• Positive tissue biopsy result
• Gangrenous skin tissue
• Erythema
• Pain on the affected site

Desired Outcome

The patient will be able to experience optimal wound healing and avoid the spread of infection to the rest of the skin to preserve its integrity.

Interventions	Rationales
Assess vital signs and monitor the signs of infection.	To establish baseline observations and check the progress of the infection as the patient receives medical treatment.
Prepare the patient for surgical debridement.	It involves the resection of the gangrenous tissue to prevent further spread of the condition to other vital organs. It involves extensive and complete removal of dead tissue even beyond the area of necrosis.
Place silver-containing dressings on the affected site/s after each debridement.	Dressings containing silver compounds are helpful in addressing the topical and direct antibiotic treatment of the affected tissues.
Administer the prescribed antibiotics.	To treat the underlying bacterial cause of necrotizing fasciitis.
Encourage proper hand hygiene and skincare.	To preserve integrity to the rest of the skin.

Related FAQs

1. What is the nursing diagnosis for impaired skin integrity?

Nursing Diagnosis: Impaired skin integrity (pressure ulcers) secondary to decreased mobility as evidenced by presence of stage 2 pressure ulcer on the sacrum. Desired Outcome: Patient’s bedsore will show optimal healing, and further bedsores will be prevented.

2. What nursing interventions are essential to maintain skin integrity?

The following are strategies to promote and maintain skin integrity: Moisturize dry skin to maximize lipid barriers; moisturize at minimum twice daily. Avoid hot water during bathing; this will increase dry, cracked skin. Protect skin with a moisture lotion or barrier as indicated.

3. What is a goal for impaired skin integrity?

GOAL: Promote circulation to tissues by reducing or eliminating pressure. Possible risk factors that decrease circulation or cause unrelieved pressure to tissues: ▪ Immobility (diagnosis that leads to immobility, such as CVA, MS, end stage Alzheimer’s, etc.) ▪ Decreased sensory perception 

4. How do you promote good skin integrity?

1. KEEP THE SKIN CLEAN AND DRY: Clean the skin with a mild soap and warm water and rinse thoroughly. Gently pat dry.
2. Apply Lotions and ointments as prescribed- to prevent skin breakdown. This promotes skin integrity. …
3. Never massage over an area of skin that is reddened or there is skin breakdown.

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