Pathophysiology of Impaired Skin Integrity

 

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