Nursing Care Plan For Impaired Skin Integrity

impaired skin integrity

Nursing care plan for impaired skin integrity is a localized injury to the skin and underlying tissue, usually over a bony prominence. Impaired skin integrity often results from pressure in combination with shear and/or friction. Maybe caused by devices such as oxygen equipment, orthopedic devices, straps or tubing, as well as pressure from beds or chairs.

Formation of Pressure Ulcers

Pressure ulcers are formed due to localized injury to the skin and underlying tissue, usually over a bony prominence. Maybe caused by devices such as oxygen equipment, orthopedic devices, straps or tubing, as well as pressure from beds or chairs.

Risk Factors for Pressure Ulcer Development

• Impaired sensory Shear perception
• Alterations in LOC
• Impaired mobility Nutrition
• Hydration
• Friction
• Moisture

Stage 1

It is characterized by intact skin with non blanchable redness

Stage 2

• Partial-thickness
• skin loss
• Blister

Stage 3

• Full-thickness
• Skin loss (Fat Visible)

Stage 4

• Full-thickness
• Tissue loss (Muscle/Bone visible)

Suspected Deep-Tissue Injury

Depth unknown. 

Nursing Care Plan For Impaired Skin Integrity

Pain

Reassessment of pain and management of pain must be included in the plan of care. Provide analgesic 30 minutes prior to wound care. Consider nonpharmacological interventions.

Nursing Knowledge Base

• Prediction and prevention of pressure ulcers. Norton Scale.
• The physical and mental condition, activity, mobility, and continence.
• Braden Scale
• Sensory perception, moisture, activity, mobility, nutrition, and friction and shear

Assessment

• Skin
• Presence of ulcers
• Mobility
• Nutrition and fluid status
• Pain
• Existing wounds, appearance, character
• Wound culture

Nursing Diagnosis and Planning

• Impaired Skin Integrity
• Risk of Infection
• Impaired Nutrition: less than body requirements
• Acute or Chronic Pain
• Impaired Physical Mobility
• Ineffective Tissue Perfusion
• Impaired Tissue Integrity
• Disturbed Body Image

Implementation

• Health promotion
• Topical skin care
• Protect bony prominences, skin barriers for incontinence.
• Positioning
• Turn every 1 to 2 hours as indicated
• Support surfaces
• Decrease the amount of pressure exerted over bony prominences.
• Implementation
• Nutrition and Hydration
• Appropriate Wound Treatments
• Pain Management
• Education of Patient and Caregivers
• Psychosocial Aspects

Summary

Nursing interventions for reducing and treating pressure ulcers need to be evaluated to determine if the client has met the identified outcomes or goals. Take a Holistic, Multidisciplinary Approach. Do a Thorough Assessment…more than once. Develop an Individualized Care Plan. Put Interventions into Place Without Delay. Commit to Care.