Impaired skin integrity is meant by “damage to skin tissues e.g., subcutaneous, corneal or membrane tissues, etc. If you are having trouble while moving from one place to another, you might be suffering from impaired skin issues.”
Impaired Skin Integrity:
The largest organ of our body is skin that is a protective hindrance to your body. Impaired skin integrity nursing diagnosis helps develop an effective skin integrity care plan. As we all know that skin is safeguarding our body from all external infections that are present in heat & light or accidents etc. Skin integrity can be defined as skin strength and health. While impaired skin integrity means any damage related to skin, For example, skin injured during an accident or any misshapen causing skin harm. So to treat impaired skin integrity, the nurse should be aware of all aspects to tackle the risky conditions.
Patients that have been suffering from spinal cord problems, shear, impaired physical mobility, etc. are at high risk of impaired skin integrity. Many other factors like age, low diet, and environmental issues can also cause skin integrity issues. Overweight patients, disabled, and paralyzed patients can lead to injuries and skin damages, so the risk for impaired skin integrity is more significant for defective individuals.
To relief the affected patients, special mattresses and equipment are sometimes suggested by physicians or nurses. Wound treatment expertise should be taught to nurses who have been working on impaired skin integrity. Because skin issues are not easy to examine in a one-time session, they require multiple sessions to observe skin behavior, transient conditions. It will be helpful to create a care plan.
Factors behind Risk for Impaired Skin Integrity:
The following causes and factors help in detecting skin integrity problems and issues.
- Allergies from irritants like soap, dyes, adhesive, etc.
- Immobility problems
- Upper age problems
- Radiation related case history or edema
- Sensation related difficulties
- Pruritus or skin itching
- Shear or pressure with impaired sensation
- Mechanical reactions like surgery scratch on skin etc.
- Environmental moisture
- Low nutrition diet
- Hyperthermia patients
- Inconsistence urinary issues
Goals and Outcomes of Impaired Skin Integrity Care Plan:
Following goals and outcomes help you to reduce the risk for impaired skin integrity.
- Intact skin
- Removal of redness from skin
- Increase in skin healing
- Sufficient hydration
- Regain in physical movement
- Better nutritional plan
- Avoid in constant pressure
- Swelling removal
- Working stoma for stability
Impaired Skin Integrity Nursing Diagnosis:
Nursing diagnosis and assessments can help you to avoid skin damages and can lead you to design impaired skin integrity nursing care plans.
- Examine the status of the patient’s skin. Check that either client has healthy skin i.e., free from wounds, outbreaks, cuts, rashes, or damaged skin. Aged individual’s skin has reduced elasticity and has less moisture, so the risk for impaired skin integrity is higher in them.
- Check any fracture, muscle stretch or sacrum, etc. because areas that have been stretched are highly leading toward skin integrity problems. Light skin individuals might have a red spot on the affected area, and dark skin tones may have blue, red, or purple color on skin affected surfaces.
- Teach the patient about the pressure sensation. Most people change their position while working or sleeping; this will help them to automatically improve their pressure and reduce the risk of impaired integrity. But if an individual does not change their position for prolong time, they can result in skin ischemia.
- Pressure ulcer danger also increases during impaired skin integrity, so nurses should keep the patient under observation for a minimum of 24-48 hours and a maximum of four weeks to thoroughly study their case and changes.
- Assess the patient’s mobility, skin moisture, sensory pressure, shear, and perception daily. Sometimes it’s also known as the Braden scale.
- Monitor physical state, mental health, activity schedule, and physical mobility regarding the Norton scale so the whole situation can be easily and rapidly understandable.
- Examine the patient’s diet state, weight gain and loss, and albumin level. Make sure that albumin level must be higher than 2.5g/Dl because contrary status is at high risk for protein depletion or skin issues.
- Monitor inconsistencies about urinary routines. Fecal may result in enzymes and skin breakage. Use pads can lessen the skin breakage as compared to normal.
- Observe patient health for Edema tests or diagnosing other immunological diseases. Also, check patient radiation-related history because radiations make the skin thin and breakable.
- Monitor the patient’s routine and assess the area where the patient serves most of the time. It will help you to track shear and friction and pressure reduction.
- Skin maceration can be caused by moisture, so observe the environmental conditions regarding humidity.
- Avoid steroid usage. Prolong use of steroids may lead your skin towards injury or papery skin tone.
- Chemical irritant usage can also cause inflammation, itching, or blisters. So avoid their usage.
- Whenever risk for impaired skin integrity factors increase, visit your doctor and reassess your skin daily.
Impaired Skin Integrity Nursing Interventions:
Following interventions can assist in patient guide to recover as soon as possible. These points are also helpful in impaired skin integrity nursing diagnosis and impaired skin integrity nursing care plan development.
- Ask the victim to avoid the elevating head during lying on the bed. Instead, guide them to use trapeze or linen while transferring to bed. Because heels or elbow-rubbing with bed linen and transferring patients without lift cover can lead to impaired skin integrity.
- Arrange the right quality mattress because a mattress of 4-5 inch thick can help to reduce the pressure. Moisture can also be a catch because of their foam. This intervention is suggested especially to low-risk patients.
- Water, static, or dynamic mattresses are suggested for moderate-risk individuals because all these mattresses help in the variation of deflation or inflation.
- A water bed or fluidized therapy is suggested for high-risk and ulcer stage IV clients. These help the patient to move out of bed with ease.
- Change the patient’s position on alternate periods. It will help to avoid pressure breakdown. The bed’s head should be elevated at a 30-degree angle to prevent the slipping.
- Take care of proper nutrition and ambulation. These will be helpful to provide you strength while mobility and DLAs.
- Clean your skin twice a day with normal water. Moisture and dry the skin, especially bony prior. Such interventions resist skin injuries.
- To enhance the perfusions of skin, make sure to massage your skin daily around affected areas.
- Teach the patient about a skincare plan basic to deal in critical situations.
- If a patient is terrible at nutrition plans, guide the patient to look forward to some diet nutritionist professional.
- WOCN provide help to patients, nurses, and family member in an emergency. They help the individual to educate about prevention care plans. So contact with WOCN i.e., stand for wound, ostomy, continence, and nurse.