Domain 11. Safety-protection
Class 2. Physical injury
Diagnostic Code: 00046
Nanda label: Impaired skin integrity
Diagnostic focus: Skin integrity
Nursing diagnosis is a form of medical diagnosis specifically applied to nursing. Its basic function is to identify a challenge, disorder, or abnormality that interferes with or impedes normal functioning. In this case, the nursing diagnosis of impaired skin integrity is used when the skin and soft tissue of a patient are compromised, making them vulnerable to further injury, infection, or alterations in skin temperature and pressure. To diagnose this condition, nurses must consider many factors, including the existing state of skins integrity, the patient’s risk for developing additional skin problems, and the potential impacts on the patient's lifestyle and quality of care.
NANDA Nursing Diagnosis Definition
The National Nursing Diagnostic Association's definition of Impaired Skin Integrity identifies it as “a state in which a client has difficulty in maintaining physical, chemical, and thermal balance because of disrupted skin integrity.” The definition also states that “this problem is experienced as a breakdown of the skin, leading to increased risk for alterations in cardiovascular, immune, and respiratory systems, and overall health.”
Defining Characteristics
The defining characteristics associated with this nursing diagnosis vary depending on the cause of the skin problem. Possible subjective and objective indicators include:
Subjective Indicators:
- Pain
- Itching
- Burning sensation
- Discomfort
- Altered sensation
Objective Indicators:
- Redness
- Blistering
- Inflammation
- Weepiness
- Discoloration
There are a variety of factors that can contribute to impaired skin integrity, including lifestyle choices and environmental conditions. Lifestyle causes may include:
- Extreme temperatures
- Friction
- Pressure
- Excess moisture
- Poor hygiene
- Exposure to toxins (chemical irritants, radiation, etc.)
Environmentally-induced impairments may include:
- Contact with sharp objects
- Exposure to carnivorous animals, arachnids, or insects
- Extreme altitudes
- Inadequate clothing
- Inadequate wound care
At-Risk Populations
Patients who are at risk for impaired skin integrity include those who are elderly, have diabetes, are bedridden, and have limited mobility, as well as those who are exposed to extreme climates, corrosive substances, and traumatic events. People living with HIV/AIDS, cancer, and other chronic illnesses may also be more susceptible to skin damage.
Associated Conditions
Once skin integrity is compromised, patients may be at risk for a variety of associated conditions and complications. These include, but are not limited to, increased bleeding and bruising, fungal and bacterial infections, loss of water, electrolytes, and protein levels, and organ failure.
Suggestions of Use
Nursing diagnosis of Impaired Skin Integrity can be used to identify and assess the risk of skin damage. It can also be used to provide direction for nursing interventions and to establish eligibility for clinical care plans, such as wound care procedures or lifestyle modification recommendations.
Suggested Alternative NANDA Nursing Diagnoses
In some cases, Impaired Skin Integrity is able to be assessed using alternative NANDA nursing diagnoses. These include:
- Risk for Impaired Skin Integrity
- Ineffective Tissue Perfusion
- Impaired Wound Healing
- Impaired Physical Mobility
- Stress overload
Usage Tips
When assessing impaired skin integrity, nurses should pay close attention to the patient’s skin condition and inquire about lifestyle designs that might contribute to skin breakdown. It is also important to look for signs of infection and initiate appropriate infection control measures when needed. Finally, the nurse must consider any underlying diseases or conditions that may be contributing to the skin issues.
NOC Outcomes
Nursing Outcome Classification (NOC) provides a list of outcomes that can be used to evaluate the effectiveness of nursing interventions. Outcomes related to Impaired Skin Integrity include :
- Skin Integrity: Presence of intact, continuous skin surface; Obvious signs of trauma and injury healing; Lack of bacterial low.
- Mobility: Independent in self-care activities; Include ADLs; Maintains optimal level of physical activity.
- Health Maintenance: Desire to maintain good health.
- Well-Being: Body temperature and hydration is maintained; Energy and strength maintained; Self-rated stress level is low; Overall sense of well-being restored.
Evaluation Objectives and Criteria
When evaluating the efficacy of nursing interventions related to Impaired Skin Integrity, nurses should consider whether the goal was achieved within the expected timeframe. Specifically, nurses should evaluate the following:
- Has the patient’s skin integrity improved?
- Has the patient experienced any changes in mobility?
- Are there any visible signs of infection or further skin damage?
- Does the patient report a preparedness to adopt healthy practices?
- Has the patient resumed normal functioning and activities?
- Has the patient’s wellbeing returned to normal?
NIC Interventions
The Nurse Interventions Classification (NIC) provides an authoritative guide for interventions related to Impaired Skin Integrity. These include:
- Wound Care: Monitoring and cleaning of affected areas using appropriate techniques; Provision of wound dressings and barrier protection as needed; Updating of policies and protocols.
- Immobility Management: Restoring optimal levels of physical activity; Monitoring of joint position, range of motion and postural alignment; Facilitation of transferences and repositioning.
- Infection Control: Monitoring for possible signs of infection; Identification of risk factors for infection; Teaching of preventive methods; Implementation of infection control policies and protocols.
- Skin Hygiene: Education of proper skin care; Monitoring for evidence of redness, irritation, or breakdown; Reassessment of skin integrity; Application of barrier protection as needed.
- Environmental Monitoring: Inspection and evaluation of environmental conditions that can contribute to skin damage; Adjustment of environmental controls as needed.
- Activity Planning: Design of interventions to help patient achieve goals; Assistance so patient can safely and comfortably engage in their desired activities.
Nursing Activities
Nurses can play an active role in helping patients restore skin integrity. To do so, nurses should be prepared to provide a variety of activities and treatments, including:
- Assessment of skin and wound condition
- Application of topical treatments and wound dressings
- Provision of nutrition, fluids, and medications as prescribed
- Monitoring for signs and symptoms of infection
- Instruction on hygiene practices and prevention methods
- Reinforcement of adaptive skills and patient education
- Advocacy for patient rights and well-being
Conclusion
Maintaining skin integrity is critical for the safety and wellbeing of patients. By utilizing the nursing diagnosis of Impaired Skin Integrity, nurses can identify skin issues and work to implement interventions that will restore and protect skin. Appropriate assessment, follow-up care, and monitoring will help ensure that problems are addressed, managed, and prevented.
FAQs
- What is nursing diagnosis impaired skin integrity?
Nursing diagnosis of impaired skin integrity is used to identify a challenge, disorder, or abnormality that causes damage or inhibits normal functioning of the skin and soft tissue. - What are the defining characteristics of impaired skin integrity?
Possible subjective and objective indicators of impaired skin integrity include pain, itching, a burning sensation, discomfort, altered sensation, redness, blistering, inflammation, weepiness, and discoloration. - What environmental factors can cause impaired skin integrity?
Environmental causes of impaired skin integrity may include contact with sharp objects, exposure to carnivorous animals, arachnids, or insects, extreme altitudes, inadequate clothing, and inadequate wound care. - Who is at risk for impaired skin integrity?
Patients who are at risk for impaired skin integrity include those who are elderly, have diabetes, are bedridden, and have limited mobility, as well as those who are exposed to extreme climates, corrosive substances, and traumatic events. - What nursing activities are helpful in restoring skin integrity?
Activities that promote the restoration of skin integrity include assessment of skin and wound condition, application of topical treatments and wound dressings, provisions of nutrition, fluids, and medications, monitoring for signs and symptoms of infection, instruction on hygiene practices and prevention methods, reinforcement of adaptive skills and patient education, and advocacy for patient rights and well-being.