An impaired skin integrity nursing diagnosis and early recognition allow for prompt intervention. Implementing the risk for impaired skin integrity care plan can help prevent further complications, including discomfort and infections.
Risk factors (causes)
- Physical immbobilization/bedrest
- Edema
- Decreased tissue perfusion
- Poor nutritional state
- Impaired circulation
- Disease processes such as diabetes, autoimmune
- Moisture
- Shearing/Friction
- Obesity
Signs and Symptoms of Impaired Skin Integrity
Subjective (patient may report)
- verbal report of pain
- altered sensation at the site if tissue impairment
Objective (Nurse assesses)
- Skin color changes
- Skin redness
- Warmth of skin
- Skin areas demonstrating impairment
- Areas of decreased sensation
- Albumin
- Protein
Expected outcomes
- Patient will maintain intact skin integrity
- Patient will have timely healing of wounds without complications
- Patient will verbalize preventative measures to decrease pressure injury
- Patient will demonstrates behaviors/techniques to prevent skin breakdown
Nursing Assessment for Impaired Skin Integrity
A thorough skin assessment should include bony prominences, dependent areas, and affected extremities for pallor, redness, and breakdown. Collect patient history, including risk factors and symptoms (objective and subjective data).
Braden skin scale
The Braden scale consists of six subscales and ranges from 6-23. The lower the score, the higher the risk for pressure ulcer development.
Cardiac Assessment
- Abnormal heart
- Changes in blood pressure
Respiratory Assessment
- Changes in breathing
- Decreased oxygen saturation
Nutritional Assessment
- Decreased intake
- Poor protein intake
Neurologic/Sensory Assessment
- Pain
- Loss of sensation
- Confusion (risk of infection)
Visual appearance/labs
- Pallor
- Redness
- Breakdown of skin covering bony prominences
- Pruritic areas
- Perineum