Nursing Care Plans Impaired Skin Integrity

In this nursing care plan, we will discuss the impaired skin integrity. First, we will provide an overview of the condition and its impact on patients. Then, we will describe the nursing diagnosis and etiology of this condition. From there, you’ll learn about subjective data (such as patient history), objective data (such as lab results), assessment results (including problem identification), goals and outcome criteria for treatment interventions…and more!

Nursing Care Plans Impaired Skin Integrity

1 Impaired Skin Integrity

Impaired Skin Integrity is a wound that is open or cracking, with pain and/or bleeding.

Signs and Symptoms:

• Open wounds on the skin, with or without drainage.
• Cracked or splitting skin that is in contact with stool, urine, saliva, mucus or blood (e.g., bed sores).
• Pressure ulcers.

Etiology: Nursing Diagnoses for Impaired Skin Integrity include:

• Acute Pain related to wound exposure to incontinence products (e.g., fecal matter) or pressure from sitting on a hard surface for long periods of time; related to dressing changes for patients who cannot perform self-care activities independently; related to use of ostomy appliances; related to movement away from home environment where support system available (i.e., hospitalization).

2 Nursing Diagnosis

• Impaired skin integrity is a nursing diagnosis.
• Impaired skin integrity can be a symptom of other conditions.
• Impaired skin integrity can be caused by multiple factors.
• Impaired skin integrity can be a risk factor for other conditions.

3 Etiology

The nursing care plan for impaired skin integrity is based on the individual’s age, gender, health history, and risk factors. Risk factors may include:

• Poor nutrition
• Poor hygiene
• Infection (for example, pressure ulcers)

These risk factors can lead to impairment of skin integrity by causing or worsening conditions such as:

• Ulceration (for example, decubitus ulcers)

The nursing assessment is an important part of improving the condition of impaired skin integrity. The nurse will identify the following areas during this assessment:

4 Subjective Data

In this section, you will be able to describe the patient’s symptoms and concerns, as well as his or her understanding of the problem.

For example:

• Subjective: The patient complains of pain on the right side of his abdomen. He also notes that he has had difficulty walking due to weakness in his legs.
• Objective: Examination reveals no tenderness in the right lower quadrant, but there is a palpable mass present with an audible bruit on percussion over it. Subjectively, he reports severe pain upon palpation at this site with minimal movement allowed by him following abdominal surgery last week by another provider (you).

5 Objective Data

You will be able to:

• Explain how you would assess the patient for impaired skin integrity including a history, physical examination, laboratory tests and diagnostic procedures.
• Describe the nursing diagnoses that may be appropriate and interventions that can be implemented to promote skin integrity.

6 Assessment (Problem)

In this nursing care plan, your patient is experiencing impaired skin integrity due to the presence of a pressure ulcer. Skin integrity is compromised when the skin is damaged, irritated, or infected. It also occurs when skin is exposed to pressure, friction, or shear forces. This may result in an alteration in its function by creating a break in its structure and/or causing pain (American Nursing Association [ANA], 2011).

7 Goals and Outcome Criteria

The goals of the nursing care plan for an adult with impaired skin integrity (ISI) are to:

• Prevent further damage to the affected part of the body.
• Provide comfort measures such as fluid and nutritional support, pain management and emotional support.

Outcome criteria are used to evaluate each goal. Your outcome criteria may include:

• The client’s ability to maintain a regular sleep pattern.
• The client’s ability to take nutrition orally, per NG tube or per rectum on their own with minimal assistance from others.

8 Implementation (Nursing Interventions) with Rationales/ Justifications

• Skin care
• Debride any necrotic tissue, removing it by clipping or shaving with a razor blade.
• Remove foreign material such as gravel, grass, or dirt from the wound.
• Rinse the wound with sterile saline to remove debris and devitalized tissue. The rinse should be continued until clean water drains from the wound (see Figure 1).

9 Takeaway:

Nursing care plans are very important in nursing because they are a way to organize the patient’s needs. This article was written from the perspective of a registered nurse and has many different types of information about impaired skin integrity, including:

• How it is diagnosed
• What a nurse should do about it
• Who can help when you are having problems with your skin

Closing

In summary, the impaired skin integrity diagnosis is a serious problem that requires immediate intervention. The goals of nursing care for this condition should be to improve the quality of life and prevent further injury to the affected area.