Nursing Diagnosis: Impaired Skin integrity Application of NANDA, NOC, NIC

Nursing Diagnosis: Impaired Skin integrity
Diane Krasner

NANDA Definition: Altered epidermis and/or dermis

Defining Characteristics: Invasion of body structures; destruction of skin layers (dermis); disruption of skin surface (epidermis)

Related Factors:

External

Hyperthermia; hypothermia; chemical substance (e.g., incontinence); mechanical factors (e.g., friction, shearing forces, pressure, restraint); physical immobilization; humidity; extremes in age; moisture; radiation; medications

Internal

Altered metabolic state; altered nutritional state (e.g., obesity, emaciation); altered circulation; altered sensation; altered pigmentation; skeletal prominence; developmental factors; immunological deficit; alterations in skin turgor (change in elasticity); altered fluid status

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

·         Tissue Integrity: Skin and Mucous Membranes

·         Wound Healing: Primary Intention

·         Wound Healing: Secondary Intention

Client Outcomes

·         Regains integrity of skin surface

·         Reports any altered sensation or pain at site of skin impairment

·         Demonstrates understanding of plan to heal skin and prevent reinjury

·         Describes measures to protect and heal the skin and to care for any skin lesion

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

·         Incision Site Care

·         Pressure Ulcer Care

·         Skin Care: Topical Treatments

·         Skin Surveillance Wound Care

Nursing Interventions and Rationales

·         Assess site of skin impairment and determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, skin tear) (Krasner, Sibbald, 1999). Prior assessment of wound etiology is critical for proper identification of nursing interventions (van Rijswijk, 2001).

·         Determine that skin impairment involves skin damage only (e.g., partial-thickness wound, stage I or stage II pressure ulcer). Classify superficial pressure ulcers in the following manner:

o Stage I: Observable pressure-related alteration of intact skin with indicators as compared with the adjacent or opposite area on the body that may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues (National Pressure Ulcer Advisory Panel, 1999).

o Stage II: Partial-thickness skin loss involving epidermis or dermis superficial ulcer that appears as an abrasion, blister, or shallow crater (National Pressure Ulcer Advisory Panel, 1999).

NOTE: For wounds deeper into subcutaneous tissue, muscle, or bone (stage III or stage IV pressure ulcers), see the care plan for Impaired Tissue integrity.

·         Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection. Determine whether client is experiencing changes in sensation or pain. Pay special attention to high-risk areas such as bony prominences, skinfolds, the sacrum, and heels. Systematic inspection can identify impending problems early (Bryant, 1999).

·         Monitor client's skin care practices, noting type of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing.

·         Individualize plan according to client's skin condition, needs, and preferences. Avoid harsh cleansing agents, hot water, extreme friction or force, or cleansing too frequently (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).

·         Monitor client's continence status, and minimize exposure of skin impairment and other areas to moisture from incontinence, perspiration, or wound drainage.

·         If client is incontinent, implement an incontinence management plan to prevent exposure to chemicals in urine and stool that can strip or erode the skin. Refer to a urologist or gastroenterologist for incontinence assessment (Doughty, 1991; Wound, Ostomy, and Continence Nurses Society, 1992, 1994; Fantl et al, 1996).

·         For clients with limited mobility, use a risk-assessment tool to systematically assess immobility-related risk factors (van Rijswijk, 2001). A validated risk-assessment tool such as the Norton or Braden scale should be used to identify clients at risk for immobility-related skin breakdown (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).

·         Do not position client on site of skin impairment. If consistent with overall client management goals, turn and position client at least every 2 hours. Transfer client with care to protect against the adverse effects of external mechanical forces such as pressure, friction, and shear.

·         Evaluate for use of specialty mattresses, beds, or devices as appropriate (Fleck, 2001). If the goal of care is to keep a client (e.g., a terminally ill client) comfortable, turning and repositioning may not be appropriate. Maintain the head of the bed at the lowest possible degree of elevation to reduce shear and friction, and use lift devices, pillows, foam wedges, and pressure-reducing devices in the bed. Evaluate for the use of specialty mattresses or beds as appropriate (Krasner, Rodeheaver, Sibbald, 2001; Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992; Wilson, 1994).

·         Implement a written treatment plan for topical treatment of the site of skin impairment. A written plan ensures consistency in care and documentation (Maklebust, Sieggreen, 1996). Topical treatments must be matched to the client, wound, and setting (Krasner, Sibbald 1999).

·         Select a topical treatment that will maintain a moist wound-healing environment and that is balanced with the need to absorb exudate. Caution should always be taken not to dry out the wound (Bergstrom et al, 1994).

·         Avoid massaging around the site of skin impairment and over bony prominences. Research suggests that massage may lead to deep-tissue trauma (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).

·         Assess client's nutritional status. Refer for a nutritional consult, and/or institute dietary supplements as necessary. Inadequate nutritional intake places individuals at risk for skin breakdown and compromises healing (Demling, De Santi, 1998).

Home Care Interventions

·         Instruct and assist client and caregivers to remove or control impediments to wound healing (e.g., management of underlying disease, improved approach to client positioning, improved nutrition). Wound healing can be delayed or fail totally if impediments are not controlled (Krasner, Sibbald, 1999).

·         Initiate a consultation in a case assignment with a wound, ostomy, continence nurse (WOC nurse) to establish a comprehensive plan as soon as possible.

Client/Family Teaching

·         Teach skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing. Early assessment and intervention help prevent serious problems from developing.

·         Teach client to use a topical treatment that is matched to the client, wound, and setting. The topical treatment must be adjusted as the status of the wound changes (van Rijswijk, 2001; Krasner, Sibbald, 1999; Ovington, 1998).

·         If consistent with overall client management goals, teach how to turn and reposition at least every 2 hours. If the goal of care is to keep a client (e.g., terminally ill client) comfortable, turning and repositioning may not be appropriate (Krasner, Rodeheaver, Sibbald, 2001; Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).

·         Teach client to use pillows, foam wedges, and pressure-reducing devices to prevent pressure injury.