Domain 11. Safety-protection
Class 2. Physical injury
Diagnostic Code: 00047
Nanda label: Risk for impaired skin integrity
Diagnostic focus: Skin integrity
Skin integrity is the condition of the skin being undamaged and well-maintained. Risk for impaired skin integrity happens when the skin becomes exposed to external factors that can damage it and thus, decrease its protective mechanisms. These risks can lead to infections, pressure ulcers, burns, and other skin injuries. It is imperative for nurses to evaluate for risks for impaired skin integrity and provide interventions to help protect and maintain the skin’s integrity.
NANDA Nursing Diagnosis Definition
NANDA International defines “risk for impaired skin integrity” as “an individual at risk for alteration in the skin or (mucous) membranes related to potentially damaging factors.” As stated in the definition, nursing diagnosis of this sort is typically focused on identifying factors which promote skin and mucous membrane damage. To determine the primary cause(s) of the risk, it is essential to document the patient’s medical history and lifestyle.
The risk factors which put someone at risk for impaired skin integrity vary from person to person and depend largely upon their health status, age, chronic illnesses, and other conditions. Some of the more common risk factors include limited mobility, iron deficiency anemia, obesity, smoking, use of systemic medications (i.e. chemotherapeutic agents, glucocorticoids), and excessive sun exposure. Exposure to allergens, irritants, or allergens, such as prolonged contact with water can also place individuals at a higher risk. Identification of potential sources of skin damage is important and should be addressed through preventative strategies.
At Risk Populations
Certain groups of people are at a higher risk than the general population of developing impaired skin integrity due to biological and environmental factors. People who are elderly, bedridden, or undergoing surgical procedures are most likely to experience risk for impaired skin integrity. Likewise, individuals experiencing mental illness or poverty are also at risk for skin damage, due to lack of attention to skin care or poor living conditions.
Impaired skin integrity is often linked to other medical conditions that can cause further skin damage. Poor nutrition, immobility, bacterial or fungal infection, reduced circulation, and frequent contact with body fluids can all increase the risk for impaired skin integrity. Diabetes mellitus, vascular insufficiency, kidney failure, and obesity can also raise the risk.
Suggestions for Use
Nurses can use the NANDA nursing diagnosis of “risk for impaired skin integrity” as a way to identify potential risks for skin breakdown. Screening for risk factors and associated conditions can provide nurses with a better understanding of the risks faced by their patients. Additionally, nurses can apply preventive measures such as proper positioning, skin inspections, and keeping an eye on pressure points to help reduce the risk of impaired skin integrity.
Suggested Alternative NANDA Nursing Diagnosis
In addition to “risk for impaired skin integrity,” other NANDA nursing diagnoses that may apply include:
- Ineffective tissue perfusion related to decreased microcirculation or position – When skin and/or mucous membranes have poor circulation, they are at increased risk of damage.
- Risk for disuse syndrome related to immobility – Long periods of immobility can decrease skin strength and lead to increased risk for skin breakdown.
- Impaired skin integrity related to fragility – Patients over the age of 65, who often have fragile skin, are at higher risk for skin damage.
- Imbalanced nutrition: less than body requirements related to malnutrition – Malnutrition can weaken skin integrity and increase the risk for skin breakdown.
- Deficient fluid volume related to sweating, vomiting, and diarrhea – Fluid loss and low fluid intake can lead to dehydration, resulting in dryness of skin and subsequent skin breakdown.
It is important for nurses to be aware of any potential risks which could lead to impaired skin integrity, as well as any risk factors which may be present. Nurses should keep in mind the at-risk populations, associated conditions, and any potential lifestyle changes that could reduce skin damage. Early detection, prevention, and prompt intervention can reduce the prevalence of skin breakdown, allowing patients to enjoy improved quality of life.
The NOC outcomes used to measure success or improvement of skin integrity and care include:
- Skin Integrity – Measuring the patient’s ability to maintain intact skin
- Skin Surveillance – Measuring the patient’s ability to perform self-care activities such as skin inspections
- Tissue Perfusion – Measuring the extent to which the patient experiences tissue damage due to inadequate blood flow
- Fluid and Electrolyte Management – Measuring the patient’s ability to maintain adequate hydration
- Nutrition Management – Measuring the patient’s nutrition status
Evaluation Objectives and Criteria
The evaluation criteria used to measure success or improvement of skin integrity and care include:
- Intact Skin – The absence of any obvious signs of skin breakdown such as erythema, ulceration, scales, or maceration
- Early Detection of Skin Breakdown – The patient’s ability to identify areas of potential skin damage before it occurs and take appropriate action to prevent skin injury
- Regular Skin Inspections – The patient’s ability to conduct regular skin inspections to detect any changes in skin coloration, texture, sensation, or any other potential signs of skin breakdown
- Adequate Hydration – The patient’s ability to maintain adequate levels of bodily hydration
- Nutritional Status – The patient’s ability to meet their nutritional needs in order to support healthy skin integrity
The NIC interventions used to maintain or improve skin integrity and care include:
- Positioning/Mobility Support – Regular positioning and mobility support help to promote good circulation and movement, both of which are important for maintaining intact skin.
- Oral Care – Proper oral hygiene helps to reduce the growth of bacteria on the skin, which can lead to skin breakdown.
- Wound Care – Wound care is essential for healing and preventing skin breakdown.
- Nutrition Support – Providing nutritional support to ensure adequate nutrient intake promotes healthy skin integrity.
- Hydration Support – Hydration support includes providing patients with adequate amounts of liquids to ensure their bodies stay hydrated and their skin stays lubricated.
- Debridement/Excision – Debridement and excision are effective methods for removing dead tissue and treating skin lesions.
Nursing activities used to maintain or improve skin integrity and care include:
- Evaluating skin integrity – Evaluating the skin regularly for signs of damage or infection
- Providing/Teaching care – Teaching patients how to properly care for their skin and encouraging them to take part in self-care activities
- Promoting adequate nutrition – Promoting diets rich in foods containing essential nutrients to support healthy skin
- Improving mobility – Enhancing mobility to reduce the risk of skin breakdown, enhance circulation, and encourage movement
- Providing wound care – Wound care includes the application of dressings and other forms of treatment to prevent the development of further skin breakdown
- Providing hydration support – Encouraging patients to drink sufficient amounts of water to ensure their skin stays hydrated
This article has discussed and outlined the risks for impaired skin integrity, associated conditions, solutions, and interventions that nurses can use to help prevent and manage skin problems. It is important for nurses to recognize and assess any potential risks which may lead to skin breakdown, so that preventative measures can be taken. Early detection, prevention, and prompt intervention can reduce the incidence of skin breakdown, allowing individuals to enjoy improved quality of life.
- What is impaired skin integrity?
Impaired skin integrity is the condition of the skin becoming damaged or compromised as a result of external factors such as prolonged contact with water, prolonged immobility, or poor nutrition.
- What are some risk factors for impaired skin integrity?
Risk factors for impaired skin integrity can include limited mobility, iron deficiency anemia, obesity, smoking, use of systemic medications, excessive sun exposure, exposure to allergens or irritants, and more.
- Who is at risk for impaired skin integrity?
Elderly people, bedridden individuals, those undergoing surgery, those experiencing mental illness, and those in poverty are among the individuals most at risk for impaired skin integrity.
- What interventions can be used to help prevent impaired skin integrity?
Nursing interventions can include proper positioning, skin inspections, oral care, wound care, adequate hydration, and nutrition support.
- What evaluation criteria should be used to measure success or improvement of skin integrity and care?
Evaluation criteria can include intact skin, early detection of skin breakdown, regular skin inspections, adequate hydration, and nutrition status.