NURSING DIAGNOSIS: Actual/Risk for impaired tissue integrity

related to:
  1. presence of cutaneous infections such as folliculitis, herpes zoster or simplex, bullous impetigo, bacillary angiomatosis, molluscum contagiosum, and/or abscesses;
  2. presence of certain skin disorders (e.g. seborrheic dermatitis, photodermatitis, psoriasis);
  3. skin lesions associated with Kaposi's sarcoma if present;
  4. excessive scratching associated with pruritus (can occur with certain skin disorders or as a side effect of some medications such as trimethoprim-sulfamexazole);
  5. increased skin fragility associated with malnutrition;
  6. persistent contact with irritants associated with diarrhea;
  7. damage to the skin and/or subcutaneous tissue associated with prolonged pressure on tissues, friction, or shearing if mobility is decreased.
Desired Outcome
The client will maintain and/or regain tissue integrity as evidenced by:
  1. absence of redness and irritation
  2. no skin breakdown.
Nursing Actions and Selected Purposes/Rationales
  1. Assess the client for the presence of cutaneous lesions (e.g. vesicles, pustules, papules, plaques, scaling patches, nodules).
  2. Assess bony prominences, perineum, and dependent and pruritic areas for pallor, redness, and breakdown.
  3. Implement measures to treat existing cutaneous conditions:
    1. administer antimicrobial agents if ordered to treat cutaneous infections
    2. apply topical corticosteroids if ordered to treat inflammatory skin conditions
    3. cleanse infected lesions with antibacterial/antifungal solutions if ordered
    4. 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.
  4. Implement measures to prevent additional tissue breakdown:
    1. assist client to turn at least every 2 hours
    2. 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
    3. gently massage around reddened areas at least every 2 hours
    4. 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
    5. lift and move client carefully using a turn sheet and adequate assistance
    6. 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
    7. instruct or assist client to shift weight at least every 30 minutes
    8. keep client's skin clean
    9. keep bed linens dry and wrinkle-free
    10. 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
    11. provide elbow and heel protectors if indicated
    12. increase activity as allowed and tolerated
    13. perform actions to maintain an adequate nutritional status (see Diagnosis 3, action c)
    14. perform actions to prevent skin irritation resulting from diarrhea:
      1. implement measures to reduce diarrhea (see Diagnosis 9, action d)
      2. assist client to thoroughly cleanse and dry perineal area with soft tissue or cloth after each bowel movement; apply a protective ointment or cream
      3. apply a fecal incontinence pouch if diarrhea is severe
      4. if use of underpads or absorbent undergarments is necessary, select those that effectively absorb moisture and keep it away from the skin
    15. perform actions to prevent skin irritation resulting from scratching:
      1. implement measures to relieve pruritus (e.g. use a mild soap for bathing, add cornstarch or baking soda to bath water, administer prescribed antihistamines)
      2. keep nails trimmed and/or apply mittens if necessary
      3. instruct client to apply firm pressure to pruritic areas rather than scratching
    16. 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).
  5. If tissue breakdown occurs or existing breakdown progresses:
    1. notify appropriate health care provider (e.g. wound care specialist, physician)
    2. perform care of involved areas as ordered or per standard hospital procedure.