Impaired Skin Integrity Nursing Care Plan

Actual Nursing Care Plan example from Nursing for Life Organization

1. Nursing Care Plan
"Impaired Skin Integrity"
Patient
Problem
( Actual )

Nursing diagnosis \ Impaired skin integrity related to (contributing factor
according to the patient’s condition)

Subjective
Data
 According to the nurse’s observation.
Objective
Data
 According to the patient description.
Objectives

Short term


In 2 days, the patient will…
 Report any altered sensation or pain at site of tissue impairment.
 Demonstrate understanding of plan to heal tissue and prevent injury.
 Describe measures to protect and heal the tissue, including wound care.

Long term

In 2 weeks, the patient will…
 Patient’s wound decreases in size and has increased granulation tissue.
Nursing intervention

Assessment


 Determine etiology (e.g., acute or chronic wound, burn, dermatological
lesion, pressure ulcer, leg ulcer).
- Rationale: Prior assessment of wound etiology is critical for proper
identification of nursing interventions.

 Assess site of impaired tissue integrity and its condition.
- Rationale: Redness, swelling, pain, burning, and itching are indication of
inflammation and the body’s immune system response to localized tissue
trauma or impaired tissue integrity.

 Assess characteristics of wound, including color, size (length, width,
depth), drainage, and odor.
- Rationale: These findings will give information on extent of the impaired
tissue integrity or injury. Pale tissue color is a sign of decreased
oxygenation. Odor may be a result of presence of infection on the site; it
may also be coming from a necrotic tissue. Serous exudate from a wound

2. is a normal part of inflammation and must be differentiated from pus or
purulent discharge, which is present in infection.
 Assess changes in body temperature, specifically increased in body
temperature.
- Rationale: Fever is a systemic manifestation of inflammation and may
indicate the presence of infection.

 Assess the patient’s level of distress.
- Rationale: Pain is part of the normal inflammatory process. The extent
and depth of injury may affect pain sensations.

 Know signs of itching and scratching.
- Rationale: The patient who scratches the skin in attempts to alleviate
extreme itching may open skin lesion and increase risk for infection.


 Assess patient’s nutritional status; refer for a nutritional consultation
and/or institute dietary supplements.
- Rationale: Inadequate nutritional intake places the patient at risk for skin
breakdown and compromises healing further causing impaired tissue
integrity.


 Classify pressure ulcers by assessing the extent of tissue damage.
- Rationale:
 Wound assessment is more reliable when classified in such manner
according to the National Pressure Ulcer Advisory Panel. The following are
the stages of pressure ulcers:

 Stage I. Nonblanchable erythema signaling potential ulceration.
 Stage II. Partial-thickness skin loss (abrasion, blister, or a shallow crater)
involving the epidermis and may extend through the dermis.
 Stage III. full-thickness skin loss involving damage to or necrosis of
subcutaneous tissue that may extend down to but not through underlying
fascia; ulcer appears as a deep crater with or without undermining of
adjacent tissue.
 Stage IV. Full-thickness skin loss with extensive destruction; tissue
necrosis; or damage to muscle, bone, or supporting structures (e.g.,
tendons, joint capsules)

3. Interventions

 Monitor site of impaired tissue integrity at least once daily for color
changes, redness, swelling, warmth, pain, or other signs of infection.
- Rationale: Systematic inspection can identify impending problems early.

 Monitor status of skin around wound. Monitor patient’s skin care
practices, noting the type of soap or other cleansing agents used,
temperature of water, and frequency of skin cleansing.
- Rationale: Individualize plan is necessary according to patient’s skin
condition, needs, and preferences.

 Provide tissue care as needed.
- Rationale: Each type of wound is best treated based on its etiology. Skin
wounds may be covered with wet or dry dressings, topical creams or
lubricants, hydrocolloid dressings (e.g., DuoDerm) or vapor-permeable
membrane dressings such as Tegaderm. An eye patch or hard, plastic
shield for corneal injury. The dressing replaces the protective function of
the injured tissue during the healing process.

 Keep a sterile dressing technique during wound care.
- Rationale: This technique reduces the risk of infection in impaired tissue
integrity.

 Premedicate for dressing changes as necessary.
- Rationale: Manipulation of profound or extensive cuts or injuries may be
painful.

 Wet thoroughly the dressings with sterile normal saline solution before
removal.
- Rationale: Saturating dressings will ease the removal by loosening
adherents and decreasing pain, especially with burns.

 Monitor patient’s continence status and minimize exposure of skin
impairment site and other areas to moisture from incontinence,
perspiration, or wound drainage.
- Rationale: This is to prevent exposure to chemicals in urine and stool that
can strip or erode the skin causing further impaired tissue integrity.

 If patient is incontinent, implement an incontinence management plan.
- Rationale: This is to prevent exposure to chemicals in urine and stool that
can strip or erode the skin.
-
 Administer antibiotics as ordered.
Rationale: Wound infections may be managed well and more efficiently with
topical agents, although intravenous antibiotics may be indicated.

4.  Tell patient to avoid rubbing and scratching. Provide gloves or clip the nails
if necessary.
- Rationale: Rubbing and scratching can cause further injury and delay
healing.

 Encourage a diet that meets nutritional needs.
- Rationale: A high-protein, high-calorie diet may be needed to promote
healing.

 Do not position the patient on site of impaired tissue integrity. If ordered,
turn and position patient at least every 2 hours, and carefully transfer
patient.
- Rationale: This is to avoid the adverse effects of external mechanical
forces (pressure, friction, and shear).

Health Teaching


 Educate patient about proper nutrition, hydration, and methods to
maintain tissue integrity.
- Rationale: The patient needs proper knowledge of his or her condition to
prevent impaired tissue integrity.

 Teach skin and wound assessment and ways to monitor for signs and
symptoms of infection, complications, and healing.
- Rationale: Early assessment and intervention help prevent the
development of serious problems.

 Instruct patient, significant others, and family in the proper care of the
wound including hand washing, wound cleansing, dressing changes, and
application of topical medications).
- Rationale: Accurate information increases the patient’s ability to manage
therapy independently and reduce the risk for infection.

 Encourage the use of pillows, foam wedges, and pressure-reducing
devices.
- Rationale: To prevent pressure injury.
-
 Educate the patient the need to notify the physician or nurse.
- Rationale: This is to prevent further impaired tissue integrity
complications.

5. Evaluation

Achieved ( ) Partially achieved ( ) Not achieved ( )

Evidence by:





Important Note
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interventions may change according to patient condition. You should consider this, search,
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