Nursing Diagnosis: Application to Clinical Practice
11th Edition

Impaired Skin Integrity
DEFINITION
Impaired Skin Integrity: State in which a person experiences or is at risk for damage to the epidermal and dermal tissue
DEFINING CHARACTERISTICS
Major (Must Be Present)
Disruptions of epidermal and dermal tissue
Minor (May Be Present)
  • Denuded skin
  • Lesions (primary, secondary)
  • Erythema
  • Pruritus
RELATED FACTORS
Focus Assessment Criteria
P.585

Goal
The person will demonstrate skin integrity free of pressure ulcers (if able)
Indicators
  • Participate in risk assessment.
  • Express willingness to participate in prevention of pressure ulcers.
  • Describe etiology and prevention measures.
  • Explain rationale for interventions.
General Interventions
Use a Formal Risk Assessment Scale to Identify Individual Risk Factors in Addition to Activity and Mobility Deficits (eg, The Braden Scale, Worton Score [AHCPR, 1992]); Refer to Focus Assessment
Assess for Skin Deficits
  • Dryness
  • Thinness
  • Edema
  • Excessive perspiration
  • Obesity
Assess for Impaired Oxygen Transport
  • Edema
  • Arteriosclerosis
  • Anemia
  • Cardiopulmonary disorders
  • Peripheral vascular disorders
Assess for Chemical/Mechanical/Thermal Irritants
  • Radiation
  • Spasms
  • Incontinence (feces, urine)
  • Casts, splints, braces
Assess for Nutritional Deficits
  • Protein
  • Dehydration
  • Vitamin
  • Mineral and trace element
Assess for Systemic Disorders
  • Infection
  • Hepatic or renal disorders
  • Diabetes mellitus
  • Cancer
Assess for Sensory Deficits
  • Neuropathy
  • Cord injury
  • Confusion
  • Head injury
Assess for Immobility
Attempt to Modify Contributing Factors to Lessen the Possibility of a Pressure Ulcer Developing
Incontinence of Urine or Feces
Determine etiology of incontinence.
Maintain sufficient fluid intake for adequate hydration (approximately 2,500 mL daily, unless contraindicated); check oral mucous membranes for moisture and check urine specific gravity.
Establish a schedule for emptying bladder (begin with every 2 h).
If person is confused, determine what his or her incontinence pattern is and intervene before incontinence occurs.
Explain problem to client; secure his or her cooperation for the plan.
When incontinent, wash perineum with a liquid soap that does not alter skin pH.
Apply a protective barrier to the perineal region (incontinence film barrier spray or wipes).
Check person frequently for incontinence when indicated.
For additional interventions, refer to Impaired Urinary Elimination.
Immobility
Encourage range-of-motion exercises and weight-bearing mobility, when possible, to increase blood flow to all areas.
Promote optimal circulation when in bed.
  • Use repositioning schedule that relieves vulnerable area most often (eg, if vulnerable area is the back, turning schedule would be left side to back, back to right side, right side to left side, and left side to back); post “turn clock” at bedside.
  • P.586

  • Turn or instruct client to turn or shift weight every 30 min to 2 h, depending on other causative factors and the ability of the skin to recover from pressure.
  • Increase frequency of the turning schedule if any reddened areas that appear do not disappear within 1 h after turning.
  • Place person in normal or neutral position with body weight evenly distributed. Use 30-degree laterally inclined position when possible.
  • Keep bed as flat as possible to reduce shearing forces; limit semi-Fowler’s position to only 30 min at a time.
  • Use foam blocks or pillows to provide a bridging effect to support the body above and below the high-risk or ulcerated area so affected area does not touch bed surface. Do not use foam donuts or inflatable rings because these increase the area of pressure.
  • Alternate or reduce the pressure on the skin with an appropriate support surface.
  • Suspend heels off bed surface
Use enough personnel to lift person up in bed or chair rather than pull or slide skin surfaces.
Have person wear long-sleeved top and socks to reduce friction on elbows and heels.
To reduce shearing forces, support feet with footboard to prevent sliding.
Promote optimal circulation when person is sitting.
  • Limit sitting time for person at high risk for ulcer development.
  • Instruct person to lift self using chair arms every 10 min, if possible, or assist person in rising up off the chair at least every hour, depending on risk factors present.
  • Do not elevate legs unless calves are supported, to reduce the pressure over the ischial tuberosities.
  • Pad chair with pressure-relieving cushion
Inspect areas at risk of developing ulcers with each position change.
  • Ears
  • Trochanter*
  • Sacrum
  • Elbows
  • Heels*
  • Scapula
  • Occiput
  • Ischia
  • Scrotum
Observe for erythema and blanching and palpate for warmth and tissue sponginess with each position change.
Do not rub reddened areas. To avoid damaging the capillaries, do not perform massage.
Malnourished State
Consult a dietitian.
Increase protein and carbohydrate intake to maintain a positive nitrogen balance; weigh the person daily and determine serum albumin level weekly to monitor status.
Ascertain that daily intake of vitamins and minerals is maintained through diet or supplements (see Key Concepts for recommended amounts).
See Imbalanced Nutrition: Less Than Body Requirements for additional interventions.
Sensory Deficit
Inspect person’s skin daily, because he will not experience discomfort.
Teach person or family to inspect skin with mirror.
Initiate Health Teaching, as Indicated
Instruct person and family in specific techniques to use at home to prevent pressure ulcers.
Consider the use of long-term pressure-relieving devices for permanent disabilities.
Rationales
  • Pressure is a compressing downward force on a given area. If pressure against soft tissue is greater than intracapillary blood pressure (approximately 32 mm Hg), the capillaries can be occluded, and the tissue can be damaged as a result of hypoxia.
  • Shear is a parallel force in which one layer of tissue moves in one direction and another layer moves in the opposite direction. If the skin sticks to the bed linen and the weight of the sitting body makes the skeleton slide down inside the skin, the subepidermal capillaries may become angulated and pinched, resulting in decreased perfusion of the tissue.
  • Friction is the physiologic wearing away of tissue. If the skin is rubbed against the bed linens, the epidermis can be denuded by abrasion.
  • Maceration is a mechanism by which the tissue is softened by prolonged wetting or soaking. If the skin becomes waterlogged, the cells are weakened and the epidermis is easily eroded.
  • P.587

  • Pressure reduction is the one consistent intervention that must be included in all pressure ulcer treatment plans.
  • A pressure-reducing surface must not be able to be fully compressed by the body. To be effective, a support surface must be capable of first being deformed and then redistributing the weight of the body across the surface. Comfort is not a valid criterion for determining adequate pressure reduction. A hand check should be performed to determine if the product is effectively reducing pressure. The palm is placed under the pressure-reducing mattress; if the client can feel the hand or the caregiver can feel the client, the pressure is not adequate (AHCPR, 1992; Bergstrom et al., 1994).
  • Adequate nutrition (protein, vitamins, minerals) is vital for healing wounds, preventing infection, preserving immune function, and minimizing loss of strength (Maklebust & Sieggreen, 2000).
Footnote
*Areas with little soft tissue over a body prominence are at greatest risk.
RELATED TO THE EFFECTS OF PRESSURE, FRICTION, SHEAR, MACERATION
Goal
The person will demonstrate progressive healing of dermal ulcer
Indicators
  • Identify causative factors for pressure ulcers.
  • Identify rationale for prevention and treatment.
  • Participate in the prescribed treatment plan to promote wound healing.
General Interventions
Identify the Stage of Pressure Ulcer Development (AHCPR, 1992)
Stage I: Nonblanchable erythema of intact skin
Stage II: Ulceration of epidermis and/or dermis
Stage III: Ulceration involving subcutaneous fat
Stage IV: Extensive ulceration penetrating muscle, bone, or supporting structurem
Reduce or Eliminate Factors that Contribute to the Extension of Pressure Ulcers; Refer to Risk for Impaired Skin Integrity Related to Immobility.
Prevent Deterioration of the Ulcer
Wash reddened area gently with mild soap, rinse area thoroughly to remove soap, and pat dry.
Avoid massage of bony prominence to stimulate circulation.
Protect the healthy skin surface with one or a combination of the following:
  • Apply a thin coat of liquid copolymer skin sealant.
  • Cover area with moisture-permeable film dressing.
  • Cover area with a hydrocolloid wafer barrier and secure with strips of 1-inch tape; leave in place for 2 to 3 days
Increase dietary intake to promote wound healing.
  • Initiate calorie count. Consult dietitian.
P.588

Increase protein and carbohydrate intake to maintain a positive nitrogen balance. Weigh daily and determine serum albumin level weekly to monitor status.
Ascertain that client maintains daily intake of vitamins and minerals through diet or supplements (see Key Concepts for recommended amounts).
See Imbalanced Nutrition: Less Than Body Requirements for additional interventions.
Devise Plan for Pressure Ulcer Management Using Principles of Moist Wound Healing (Maklebust & Sieggreen, 2000)
Assess status of pressure ulcer. (Bates-Jensen, 1990).*
Assess size—measure longest and widest wound surface.
Assess depth:
  • No break in skin
  • Abrasion or shallow crater
  • Deep crater
  • Necrosis
  • Involved tendon, joint capsule
Assess edges.
  • Attached
  • Not attached
  • Fibrotic
Assess undermining:
  • <2 cm
  • 2 to 4 cm
  • >4 cm
  • Tunneling
Assess necrotic tissue type (color, consistency, adherence) and amount.
Assess exudate type and amount.
Assess surrounding skin color.
Check for any peripheral edema and induration.
Assess for granulation tissue.
Assess for epithelialization.
Débride necrotic tissue (collaborate with physician).
Flush ulcer base with sterile saline solution. Avoid use of harsh antiseptic solutions.
Protect granulating wound bed from trauma and bacteria. Insulate wound surface.
Cover pressure ulcer with a sterile dressing that maintains a moist environment over the ulcer base (eg, film dressing, hydrocolloid wafer dressing, moist gauze dressing). Do not occlude ulcers on immunocompromised patients.
Avoid the use of drying agents (heat lamps, Maalox, Milk of Magnesia).
Monitor for clinical signs of wound infection.
Measure pressure ulcer weekly to determine progress of wound healing.
Consult with Nurse Specialist or Physician for Treatment of Necrotic, Infected, or Deep Pressure Ulcers
Initiate Health Teaching and Referrals, as Indicated
Instruct person and family on care of ulcers.
Teach the importance of good skin hygiene and optimal nutrition.
Refer to community nursing agency if additional assistance at home is needed.
Rationales
  • See Rationale for Impaired Skin Integrity.
  • Wound healing occurs most efficiently with the following extrinsic factors (Maklebust & Sieggreen, 2000):
    • Humidity affects the rate of epithelialization and the amount of scar formation. A moist environment provides optimal conditions for rapid healing.
    • When wounds are left uncovered, epidermal cells must migrate under the scab and over the fibrous tissue below. When wounds are semioccluded and the surface of the wound remains moist, epidermal cells migrate more rapidly over the surface.
    • P.589

    • Appropriate use of dressings may promote moist wound. Use of semiocclusive film dressings or hydrocolloid barrier wafers mechanically protect and properly humidify wounds that are epidermal or dermal. These dressings bathe the wound in serous exudate and do not adhere to the wound surface when they are removed. A physician’s order may be required.
  • Rationales for topical treatment (Maklebust & Sieggreen, 2000) are as follows:
    • Remove necrotic tissue, which delays wound healing by prolonging the inflammatory phase.
    • Cleanse wound bed to decrease bacterial count. Bacterial counts above 105 may produce infection by overwhelming the host.
    • Obliterate dead space in wound, which prevents premature closure and abscess formation.
    • Absorb excess exudate, which macerates surrounding skin and increases risk of infection in wound bed.
    • Maintain a moist wound surface, which promotes cellular migration. Dry wound surfaces delay epithelialization secondary to difficult cellular migration.
    • Insulate the wound surface; this enhances blood flow and increases epidermal migration.
    • Protect the healing wound from trauma and bacterial invasion. Open wounds are vulnerable to abrasion, contamination, drying, and shear mechanisms.
Footnote
*Refer to citation for the complete Pressure Sore Status tool and directions for scoring.