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Impaired Skin Integrity — Nursing Care Plan
Definition: Impaired skin integrity: Alteration in epidermis and/or dermis (partial-thickness) or deeper tissues (full-thickness) caused by pressure, friction, shear, moisture, vascular insufficiency, surgical incision, trauma, or disease.
Assessment
Nursing history: onset, duration, cause (pressure, burn, surgical wound, moisture-associated dermatitis, vascular insufficiency), pain level, prior wound history, mobility, continence, nutrition, comorbidities (diabetes, peripheral vascular disease), medications (steroids, anticoagulants).
Physical assessment: wound location, size (length × width × depth), stage (for pressure injuries), wound bed tissue type (granulation, slough, necrosis), exudate amount/color/odor, peri-wound skin condition, presence of tunneling/undermining, signs of infection (erythema, warmth, increasing pain, purulent drainage, fever), vascular status (capillary refill, pulses), sensation.
Risk assessment: Braden Scale or other validated pressure ulcer risk tool, activity and mobility level, nutritional status (weight change, albumin/prealbumin), skin moisture, recent friction/shear events.
Diagnostic tests: wound culture if infection suspected, blood glucose/HbA1c, CBC, serum albumin/prealbumin, Doppler studies if arterial/venous insufficiency suspected.
Nursing Diagnoses (common)
Impaired skin integrity related to pressure/immobility, moisture, friction, surgical incision, or vascular insufficiency.
Risk for infection related to open wound.
Acute or chronic pain related to wound and tissue damage.
Impaired tissue perfusion (peripheral) related to vascular disease.
Imbalanced nutrition: less than body requirements related to increased metabolic demands of wound healing or inadequate intake.
Risk for impaired physical mobility related to pain or wound care restrictions.
Planning — Goals (examples) Short-term goals (within days)
Client will demonstrate decreased wound drainage and no signs of infection.
Client will report pain control adequate for participation in wound care. Long-term goals (within weeks)
Wound size will decrease by specified percentage (e.g., 30%) within 2–4 weeks.
Wound bed will demonstrate healthy granulation tissue and epithelialization.
Peri-wound skin will remain intact and free from maceration.
Nursing Interventions and Rationale
Inspect skin and wound at least once per shift and after dressing changes; document size, depth, exudate, odor, and peri-wound condition.
Rationale: Regular assessment detects changes early, guides treatment, and tracks healing progress.
Perform wound cleansing with normal saline or prescribed solution; follow facility protocol for irrigation and cleansing technique.
Rationale: Gentle cleansing removes debris and reduces microbial load without damaging viable tissue.
Debride nonviable tissue as ordered (autolytic, enzymatic, mechanical, sharp, or surgical care by qualified provider).
Rationale: Removal of necrotic tissue promotes granulation and reduces infection risk.
Choose and apply appropriate dressing based on wound characteristics (moisture balance, amount of exudate, presence of slough, need for autolytic debridement).
Rationale: Appropriate dressing maintains a moist wound environment, protects from contamination, and manages exudate to optimize healing.
Use infection-control measures: hand hygiene, sterile technique when indicated, change dressings per policy, culture wound if signs of infection.
Rationale: Prevents wound contamination and systemic infection.
Offload pressure and reduce shear/friction: reposition every 2 hours (or per individualized plan), use pressure-redistribution surfaces (special mattresses, cushions), elevating heels, avoid sliding in bed.
Rationale: Eliminating pressure and shear is essential to prevent progression and promote healing of pressure-related wounds.
Manage moisture: maintain dry peri-wound skin, use moisture barriers for incontinent patients, promptly cleanse and change linens.
Rationale: Excess moisture (maceration) damages skin and increases risk for breakdown.
Optimize nutrition and hydration: collaborate with dietitian; encourage adequate protein (1.25–1.5 g/kg/day if malnourished), calories, vitamins (A, C), zinc, and fluid intake; consider supplements if indicated.
Rationale: Nutritional support is critical for collagen synthesis, immune function, and wound repair.
Control blood glucose in diabetic patients: monitor and collaborate with provider for glycemic management.
Rationale: Hyperglycemia impairs wound healing and increases infection risk.
Manage pain: assess pain before, during, and after wound care; provide analgesia as prescribed.
Impaired Skin Integrity — Nursing Care Plan
Definition: Impaired skin integrity: Alteration in epidermis and/or dermis (partial-thickness) or deeper tissues (full-thickness) caused by pressure, friction, shear, moisture, vascular insufficiency, surgical incision, trauma, or disease.
Assessment
Nursing history: onset, duration, cause (pressure, burn, surgical wound, moisture-associated dermatitis, vascular insufficiency), pain level, prior wound history, mobility, continence, nutrition, comorbidities (diabetes, peripheral vascular disease), medications (steroids, anticoagulants).
Physical assessment: wound location, size (length × width × depth), stage (for pressure injuries), wound bed tissue type (granulation, slough, necrosis), exudate amount/color/odor, peri-wound skin condition, presence of tunneling/undermining, signs of infection (erythema, warmth, increasing pain, purulent drainage, fever), vascular status (capillary refill, pulses), sensation.
Risk assessment: Braden Scale or other validated pressure ulcer risk tool, activity and mobility level, nutritional status (weight change, albumin/prealbumin), skin moisture, recent friction/shear events.
Diagnostic tests: wound culture if infection suspected, blood glucose/HbA1c, CBC, serum albumin/prealbumin, Doppler studies if arterial/venous insufficiency suspected.
Nursing Diagnoses (common)
Impaired skin integrity related to pressure/immobility, moisture, friction, surgical incision, or vascular insufficiency.
Risk for infection related to open wound.
Acute or chronic pain related to wound and tissue damage.
Impaired tissue perfusion (peripheral) related to vascular disease.
Imbalanced nutrition: less than body requirements related to increased metabolic demands of wound healing or inadequate intake.
Risk for impaired physical mobility related to pain or wound care restrictions.
Planning — Goals (examples) Short-term goals (within days)
Client will demonstrate decreased wound drainage and no signs of infection.
Client will report pain control adequate for participation in wound care. Long-term goals (within weeks)
Wound size will decrease by specified percentage (e.g., 30%) within 2–4 weeks.
Wound bed will demonstrate healthy granulation tissue and epithelialization.
Peri-wound skin will remain intact and free from maceration.
Nursing Interventions and Rationale
Inspect skin and wound at least once per shift and after dressing changes; document size, depth, exudate, odor, and peri-wound condition.
Rationale: Regular assessment detects changes early, guides treatment, and tracks healing progress.
Perform wound cleansing with normal saline or prescribed solution; follow facility protocol for irrigation and cleansing technique.
Rationale: Gentle cleansing removes debris and reduces microbial load without damaging viable tissue.
Debride nonviable tissue as ordered (autolytic, enzymatic, mechanical, sharp, or surgical care by qualified provider).
Rationale: Removal of necrotic tissue promotes granulation and reduces infection risk.
Choose and apply appropriate dressing based on wound characteristics (moisture balance, amount of exudate, presence of slough, need for autolytic debridement).
Rationale: Appropriate dressing maintains a moist wound environment, protects from contamination, and manages exudate to optimize healing.
Use infection-control measures: hand hygiene, sterile technique when indicated, change dressings per policy, culture wound if signs of infection.
Rationale: Prevents wound contamination and systemic infection.
Offload pressure and reduce shear/friction: reposition every 2 hours (or per individualized plan), use pressure-redistribution surfaces (special mattresses, cushions), elevating heels, avoid sliding in bed.
Rationale: Eliminating pressure and shear is essential to prevent progression and promote healing of pressure-related wounds.
Manage moisture: maintain dry peri-wound skin, use moisture barriers for incontinent patients, promptly cleanse and change linens.
Rationale: Excess moisture (maceration) damages skin and increases risk for breakdown.
Optimize nutrition and hydration: collaborate with dietitian; encourage adequate protein (1.25–1.5 g/kg/day if malnourished), calories, vitamins (A, C), zinc, and fluid intake; consider supplements if indicated.
Rationale: Nutritional support is critical for collagen synthesis, immune function, and wound repair.
Control blood glucose in diabetic patients: monitor and collaborate with provider for glycemic management.
Rationale: Hyperglycemia impairs wound healing and increases infection risk.
Manage pain: assess pain before, during, and after wound care; provide analgesia as prescribed.
