Actual/Risk for impaired tissue integrity
presence of cutaneous infections such as folliculitis, herpes zoster or simplex, bullous impetigo, bacillary angiomatosis, molluscum contagiosum, and/or abscesses;
presence of certain skin disorders (e.g. seborrheic dermatitis, photodermatitis, psoriasis);
skin lesions associated with Kaposi's sarcoma if present;
excessive scratching associated with pruritus (can occur with certain skin disorders or as a side effect of some medications such as trimethoprim-sulfamexazole);
increased skin fragility associated with malnutrition;
persistent contact with irritants associated with diarrhea;
damage to the skin and/or subcutaneous tissue associated with prolonged pressure on tissues, friction, or shearing if mobility is decreased.
The client will maintain and/or regain tissue integrity as evidenced by:
absence of redness and irritation
no skin breakdown.
Nursing Actions and Selected Purposes/Rationales
Assess the client for the presence of cutaneous lesions (e.g. vesicles, pustules, papules, plaques, scaling patches, nodules).
Assess bony prominences, perineum, and dependent and pruritic areas for pallor, redness, and breakdown.
Implement measures to treat existing cutaneous conditions:
administer antimicrobial agents if ordered to treat cutaneous infections
apply topical corticosteroids if ordered to treat inflammatory skin conditions
cleanse infected lesions with antibacterial/antifungal solutions if ordered
assist with and/or prepare client for procedures such as cryotherapy, electrocautery, curettage, incision and drainage, phototherapy, and radiation that may be performed to remove or reduce the size of cutaneous lesions.
Implement measures to prevent additional tissue breakdown:
assist client to turn at least every 2 hours
position client properly; use pressure-reducing or pressure-relieving devices (e.g. pillows, gel or foam cushions, alternating pressure mattress, air-fluidized bed) if indicated
gently massage around reddened areas at least every 2 hours
apply a thin layer of a dry lubricant such as powder or cornstarch to bottom sheet or skin and to opposing skin surfaces (e.g. axillae, beneath breasts) if indicated to reduce friction
lift and move client carefully using a turn sheet and adequate assistance
perform actions to keep client from sliding down in bed (e.g. gatch knees slightly when head of bed is elevated 30° or higher, limit length of time client is in semi-Fowler's position to 30-minute intervals) in order to reduce the risk of skin surface abrasion and shearing
instruct or assist client to shift weight at least every 30 minutes
keep client's skin clean
keep bed linens dry and wrinkle-free
thoroughly dry skin after bathing and as often as needed, paying special attention to skin folds and opposing skin surfaces (e.g. axillae, perineum); pat skin dry rather than rub
provide elbow and heel protectors if indicated
increase activity as allowed and tolerated
perform actions to maintain an adequate nutritional status (see Diagnosis 3, action c)
perform actions to prevent skin irritation resulting from diarrhea:
implement measures to reduce diarrhea (see Diagnosis 9, action d)
assist client to thoroughly cleanse and dry perineal area with soft tissue or cloth after each bowel movement; apply a protective ointment or cream
apply a fecal incontinence pouch if diarrhea is severe
if use of underpads or absorbent undergarments is necessary, select those that effectively absorb moisture and keep it away from the skin
perform actions to prevent skin irritation resulting from scratching:
implement measures to relieve pruritus (e.g. use a mild soap for bathing, add cornstarch or baking soda to bath water, administer prescribed antihistamines)
keep nails trimmed and/or apply mittens if necessary
instruct client to apply firm pressure to pruritic areas rather than scratching
apply a protective covering such as a hydrocolloid or transparent membrane dressing to areas of the skin susceptible to breakdown (e.g. coccyx, elbows, heels).
If tissue breakdown occurs or existing breakdown progresses:
notify appropriate health care provider (e.g. wound care specialist, physician)
perform care of involved areas as ordered or per standard hospital procedure.