Risk for Impaired Skin Integrity Nursing Assessment, Nursing Interventions and Rationale, and Nursing Care Plan

The Skin and Risk for Impaired Skin Integrity

Risk for Impaired Skin Integrity Nursing Assessment, Nursing Interventions and Rationale, and Nursing Care Plan

The following article seeks to address the risk for impaired skin integrity nursing assessment, nursing interventions and rationale, and nursing Care Plan. The skin is the largest organ in the human body and is a protective barrier.

What are the functions of the skin?

  • It protects the body from heat, light, injury, and infection.
  • sensation: receptor endings of nerves monitor the external environment
  • Fluid balance regulation: prevents fluid loss
  • Temp regulation: prevention of heat loss
  • Vitamin D production
  • Immune response

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. It implies having an altered dermis or epidermis. The key marker of quality care is the maintenance of skin integrity and the prevention of pressure ulcers. With this, the nurse must be aware of identifying at-risk individuals and the myriad factors that place patients at risk for skin damage.

Risk for Impaired Skin Integrity Nursing Assessment, Nursing Interventions and Rationale, and Nursing Care Plan
The Skin and Risk for Impaired Skin Integrity

  What are factors related to risk for impaired skin integrity?

            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.

Summary of factors related to risk for impaired skin integrity

  1. Mechanical forces – shearing, friction
  2. Immobility
  3. Secretions and excretions – high moisture
  4. Steroids, alt nutrition/fluid, dec circ, PVD, DM, restraints, extreme ages

Nurses should have the skills and knowledge in dealing 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 on a regular basis to ascertain whether any alterations in skin condition have transpired. Training in wound management can help in creating impaired skin integrity care plans.

Contributing Factors to Risk for Impaired Skin Integrity

What are the factors that contribute to the risk for impaired skin integrity?

  1. Chemical skin irritants (e.g., formaldehyde, hair dyes, epoxy, soaps, adhesives)
  2. Dermatitis, pruritus or itching (e.g., dry skin, allergic reactions)
  3. Extremes of age
  4. Edema
  5. Fecal or urinary incontinence
  6. History of radiation
  7. Hyperthermia or hypothermia
  8. Imbalanced nutritional state
  9. Immobility
  10. Immunological deficit
  11. Impaired circulation
  12. Impaired sensation
  13. Long-term steroid use
  14. Mechanical factors (e.g., pressure, shear, friction)
  15. Mechanical trauma (e.g., scratches, skin tear, surgical incision)
  16. Moisture
  17. Obesity

Nursing Assessment and Rationales for Risk of Impaired Skin Integrity

Risk for Impaired Skin Integrity Nursing Assessment, Nursing Interventions and Rationale, and Nursing Care Plan
Nursing Assessment and Rationales for Risk of Impaired Skin Integrity

What are the nursing assessments and rationales for risk of 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.

Assessment Rationale
Assess the overall condition of the skin.

 

Assessment of the condition of the skin provides baseline data for possible interventions for the nursing diagnosis Risk for Impaired Skin Integrity.

 

Normal skin condition differs among individuals. A 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 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 head). Specific areas where skin is stretched tautly are at higher risk for breakdown because the possibility of ischemia to 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 light pigmented skin, pressure areas appear to be red. For darker skin tones, these areas appear to be red, blue, or purple hue spots.
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 results in prolonged pressure on skin capillaries and eventually in skin ischemia.
Use an objective tool for pressure ulcer risk assessment. These are validated tool 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 at 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 a 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 bedridden patient, cushion for people in wheelchairs). Patients who spend the majority of 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 is directly related to the number of risk factors present.

 

Nursing Interventions for Risk of Impaired Skin Integrity

Risk for Impaired Skin Integrity Nursing Assessment, Nursing Interventions and Rationale, and Nursing Care Plan
Nursing Interventions for Risk of Impaired Skin Integrity

What are the nursing interventions for risk of impaired skin integrity?

            Use the following therapeutic nursing interventions for risk for impaired skin integrity in your nursing care plans.

Nursing Interventions Rationale
Discourage the patient or caregiver from elevating the head of bed repeatedly.  Encourage the use of lifting devices like trapeze or bed linen to move the patient in bed. Assessment of the condition of the skin provides Common causes of impaired skin integrity is friction which involves rubbing heels or elbows toward bed linen and moving the patient up in bed without the use of a lift sheet. A common cause of shear is elevating the head of the patient’s bed: the body’s weight is shifted downward onto the patient’s sacrum.data for possible interventions for the nursing diagnosis Risk for Impaired Skin Integrity.

 

 

Encourage the patient to change position every 15 minutes and change chair-bound positions every hour. During sitting, the pressure over the sacrum may exceed 100 mm Hg. The pressure needed to close capillaries is around 32 mm Hg; any pressure above 32 mm Hg leads to ischemia.
Encourage the implementation of pressure-relieving devices commensurate with degree of risk for skin impairment:

·         For low-risk patients: good-quality (dense, at least 5 inches thick) foam mattress overlay

 

Eggcrate-type mattresses less than 4 to 5 inches thick do not relieve pressure. Because they are made of foam, moisture can be trapped. A false sense of security with the use of these mattresses can delay initiation of devices useful in relieving pressure.
·         For moderate-risk patients: water mattress, static or dynamic air mattress

 

Dynamic devices electronically alternate inflation and deflation of the device. Static devices consist of gel, foam, water, or air that remains in a constant state of inflation. In the home, a waterbed is a good alternative.
·         For high-risk patients or those with existing stage III or IV pressure ulcers (or with stage II pressure ulcers and multiple risk factors): low-air-loss beds (Mediscus, Flexicare, KinAir) or air-fluidized therapy (Clinitron, Skytron)

 

Low-air-loss beds allow elevated head of bed and patient transfer. These should be used when pulmonary concerns necessitate elevating the head of bed or when getting the patient up is feasible. Air-fluidized therapy supports the patient’s weight at well below capillary closing pressure but restricts getting the patient out of bed easily.
Encourage the implementation of a turning schedule, restricting time in one position to 2 hours or less, if the patient is restricted to bed. Turning every 2 hours is the key to prevent breakdown. Head of bed should be kept at 30 degrees or less to avoid sliding down on bed.
Use pillows or foam wedges to keep bony prominences from direct contact with each other. Keep pillows under the heels to raise off bed. These measures reduce shearing forces on the skin.
Encourage ambulation if the patient is able. Ambulation reduces pressure on the skin from immobility thus lessening the factors that may result in impaired skin integrity.
Encourage adequate nutrition and hydration:

 

·         2000 to 3000 kcal/day (more if increased metabolic demands)

·         Fluid intake of 2000 mL/day unless medically restricted.

 

Sufficient hydration and nutrition help maintain skin turgor, moisture, and suppleness, which provide resilience to damage caused by pressure. Patients with limited cardiovascular reserve may not be able to tolerate much fluid.
Clean, dry, and moisturize skin, particularly bony prominences, twice daily or as indicated by incontinence or sweating. Avoid hot water. If powder is desirable, use medical grade cornstarch; avoid talc. Smooth, supple skin is more resistant to injury. These measures prevent evaporation away from skin. Avoid talc which may cause lung injury.
Wrap blisters with gauze or apply a hydrocolloid dressing. This prevents skin from harmful pathogens.
Massage only around affected area. This is to increase tissue perfusion. Massaging the actual reddened area may damage the skin further.
Educate patient and caregiver about the causes of pressure. This information can assist the patient or caregiver in finding methods to prevent skin breakdown.
Reinforce the importance of turning, mobility, and ambulation. These will enhance their sense of efficacy and can improve compliance with the prescribed interventions.
Communicate with a dietician as appropriate. The dietician can aid the patient and family in food preferences to meet adequate nutritional and hydration goals.
Educate patients and caregivers about proper skin care. Educating patients and caregivers methods to maintain skin integrity enhances their sense of self-efficacy and prevents skin breakdown.
Communicate with a wound, ostomy, and continence nurse (WOCN). The WOCN can assist staff, patient, and family in product selection, education, and development of a prevention plan.

 

Risk for Impaired Skin Integrity Nursing Assessment, Nursing Interventions and Rationale, and Nursing Care Plan Example
Nursing Diagnoses Interventions and Referral
Dx 1 Potential alteration in skin integrity Defining characteristics R/T immobility Observed data AMB infrequent changes in positions Measurable outcome indicator Patient will be OOB-CH within 24-72 hours post-whipple procedure; patient will change positions at least q2h; and patient will maintain good skin integrity and prevent the development of P/Us throughout their hospital stay. ·         Use pillows and pads to relieve pressure to bony parts.

·         Change positions every two hours, whether patients is in seated or lying position; use a turning clock; use a recliner for CE as he needs a hover to get out of bed; use pads and pillows as prn. Keep the bed clean, dry, and free of wrinkles.

·         Consult with PT to employ active and passive ROM to increase skin and vascular tone as indicated by patient’s condition.

Dx 2 Chronic Pain Defining characteristics R/T arthritic pain and disease process Observed data AMB irritability, grimacing and verbal preoccupation with pain Measurable outcome indicator Patient will use pharmacological and nonpharmacological pain relief strategies promptly after teaching; patient will report pain at a level less than 3 out of 10 1 hour after administering percocet; and patient will verbalize acceptable level of pain relief and gradually increase ability to engage in desired activities ·         Assess and reassess patient’s level of pain using appropriate numeric intensity.

·         Plan diversional activities with the patient to provide distraction, such as reading, crafts, television or visits.

·         Determine impact of pain on activities of daily living and promote periods of uninterrupted rest.

·         Collaborate with patient and interdisciplinary team in promotion of pain control methods and attainment of patient’s pain management goals while minimizing untoward side effects.

Dx 3 Impaired physical mobility Defining characteristics R/T inability to move (e.g., bed mobility, transfers, and ambulation) Observed data AMB limited ROM and reluctance to move Measurable outcome indicator Patient will demonstrate a willingness to implement measures to increase mobility in a week; ·         Assess the safety of the environment.

·         Evaluate patient’s ability to perform ADLs on a daily basis.

·         Assess the strength to perform ROM to all joints.

·         Refer to PT and OT for assistance with exercises.

 

References

Marcon, C., Vicari, G., Poltronieri, P., Maffissoni, A., Caregnatto, K. D. A., Argenta, C., & Adamy, E. K. (2018). NURSING DIAGNOSES OF PATIENTS UNDERGOING RADIATION THERAPY. Journal of Nursing UFPE/Revista de Enfermagem UFPE, 12(11). [Link]

Matos, A. C. G. T., Carvalho, E. S. D. S., Passos, S. D. S. S., & Silva, R. S. D. (2018). Family caregivers challenges about caring for children with impaired skin integrity. Escola Anna Nery, 22(4). [Link]

Ratliff, C. (1990). Impaired skin integrity related to radiation therapy. Journal of enterostomal therapy, 17(5), 193-198. [Link]

Risk for Impaired Skin Integrity Nursing Assessment, Nursing Interventions and Rationale, and Nursing Care Plan

 

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