Friday, November 26, 2010

Risk for Impaired Skin Integrity

Risk for Impaired Skin Integrity

NANDA Definition
At risk for skin being adversely altered Immobility, which leads to pressure, shear, and friction, is the factor most likely to put an individual at risk for altered skin integrity.

Discussion of the Problem
The skin is the largest organ in the body and serves a variety of important functions in maintaining health and protecting the individual form injury. Important nursing functions are maintaining skin integrity and promoting wound healing. Impaired skin integrity is not frequent problem for most healthy people but is a threat to elders; to clients with restricted mobility, chronic illness, or trauma; and to those undergoing invasive health care procedures. Patients who are in the highest risk for altered skin integrity are those who have spinal cord injured; confined to bed or wheelchair for prolonged periods of time; with edema; have altered sensation that triggers the normal protective weight shifting; have medical conditions such as cancer, cirrhosis of the liver, anorexia nervosa, bulimia nervosa, fecal diversions, fractures, chronic heart failure, hepatitis, renal failure, sickle cell crises, and urinary diversions. The major goals for clients at Risk for Impaired Skin Integrity are to maintain skin integrity and to avoid potential associated risks. To protect the skin and manage wounds effectively, the nurse must understand the factors affecting skin integrity, the physiology of wound healing, and specific measures that promote optimal skin conditions. In addition, prevention of skin breakdown includes a wide range of surfaces, specialty beds and mattresses, and other devices.

Nursing Interventions Classification (NIC)
  • Pressure Ulcer Prevention
  • Skin Surveillance
  • Skin Care: Topical Treatment

Nursing Outcomes Classification (NOC)
  • Risk Control
  • Risk Detection
  • Tissue Integrity: Skin and Mucous Membranes

Goal and Objectives
  • Patient will avoid dermal ischemic injury.
  • Patient will be free of or display improvement in wound or lesion healing if present.
  • Patient will demonstrate behaviors or methods to avoid skin breakdown or help healing.
  • Patient will express understanding of causal factors and nonexistence of itching.
  • Patient will recognize individual risk factors and show behaviors or methods to avoid skin breakdown.
  • Patient will report nonexistence or reduction of pruritus or scratching.
  • Patient’s skin will be kept intact, as manifested by absence of redness over bony prominences and capillary refill less than 6 seconds over areas of redness.

Subjective and Objective Data
            [Not appropriate; existence of signs and symptoms ascertains an actual diagnosis.]

Risk Factors
  • Absence of sphincter at stoma
  • Accumulation of bile salts in skin
  • Accumulation of toxins in the skin
  • Acquired immunodeficiency syndrome (AIDS)
  • Altered metabolic state
  • Altered metabolic state
  • Altered nutritional state
  • Altered sensation
  • Anemia
  • Changes in skin turgor
  • Character/flow of effluent, flatus or urine from stoma
  • Chemical substance: bile salt accumulation in the tissues
  • Decreased level of activity/immobility
  • Dehydration/cachectic changes
  • Edema
  • Effects of radiation and chemotherapy
  • Environmental moisture
  • Extremes of age
  • Hyperthermia or hypothermia
  • Immobility
  • Immunologic deficit
  • Improper fitting of appliance or removal of adhesive
  • Improper fitting/care of appliance/skin
  • Incontinence
  • Malnutrition
  • Mechanical forces (e.g., pressure, shear, friction)
  • Poor circulation
  • Presence of ascites
  • Prolonged bedrest
  • Pronounced bony prominences
  • Reaction to product/chemicals
  • Traction apparatus

Assessment (Dx)
  • Check for edema. Skin stretched tightly over edematous tissue is at great for injury.

  • Check for fecal and/or urinary incontinence. The urea in urine turns into ammonia within minutes and is scathing to the skin. Stool may have enzymes that grounds skin breakdown. Utilization of diapers and incontinence pads with plastic liners traps moisture and accelerates breakdown.

  • Evaluate general status of skin. Observe color, turgor, sensation skeletal prominences, presence of edema, areas of altered circulation or pigmentation, or emaciation. Explain or measure lesions and ntoe changes. Healthy skin differs from person to person, but must have good turgor, feel warm and dry to the touch, be free of injury, and have fast capillary refill (<6 seconds). Institute comparative baseline giving chance for timely treatment.

  • Evaluate patient’s capability to move. Immobility is the utmost risk factor in skin breakdown.

  • Evaluate patient’s consciousness of the sensation of pressure. Usually, individuals shift their weight off pressure areas each few minutes; this takes place more or less automatically, even throughout sleep. Patients with diminished sensation are unconscious of unpleasant stimuli and do not shift load. This results in protracted pressure on skin capillaries, and in the end, skin ischemia.

  • Note for environmental moisture. Moisture may add to skin maceration.

  • Note quantity of shear) and friction on patient’s skin. A usual cause of shear is raising the head of the patient’s bed: the body’s mass is shifted downward onto the patient’s sacrum. Frequent causes of friction comprise the patient rubbing heels or elbows against bed linen, and moving the patient up in bed without the utilization of a lift sheet.

  • Note surface that patient spends most of time on. Patients who use up most of the time on one surface require a pressure lessening or pressure relief device to allocate pressure more equally and decrease the risk for breakdown.

  • Particularly assess skin over bony prominences. Locations where skin is stretched tightly over bony prominences are at greater risk for breakdown due to the potential of ischemia to skin is high as an effect of compression of skin capillaries between a hard surface and the bone.

  • Re-examine skin regularly and each time the patient’s situation or management plan results in an augmented number of risk factors. The occurrence and commencement of skin breakdown is directly associated to the numeral of risk factors present.

  • Review for history of radiation therapy. Radiated skin becomes thin and friable, may have a smaller amount blood supply, and is at greater risk for breakdown.

  • Review patient’s nutritional status, including weight, weight loss, and serum albumin levels. An albumin level less than 2.5 g/dl is a severe sign, signifying grave protein reduction. Research has revealed that patients whose serum albumin is less than 2.5 g/dl are at greater risk for skin breakdown, all other factors being alike.

  • Verify age. Geriatric patients’ skin is usually less resilient and has less moisture, making for greater risk of skin injury.

  • Watch fluid intake and hydration of skin and mucous membranes. Monitors incidence of dehydration or overhydration that affect circulation and tissue integrity at the cellular level.

Therapeutic Interventions (Tx)
  • Boost tissue perfusion by offering gentle massage around reddened or blanched areas. Enhances blood flow, reducing tissue hypoxia. Note: Direct massage of compromised area may lead to tissue injury.

  • Clean, dry, and moisturize skin, particularly over bony prominences, twice daily or as necessary. If powder is desirable, utilize medical-grade cornstarch; keep away from talc. Keep cleanliness without irritating the skin.

  • Give diversional activities. Helps in refocusing attention, decreasing tendency to scratch.

  • Guard bony prominences with sheepskin, heel or elbow protectors, pillows, as necessary. Reduces pressure on tissues, avoiding skin breakdown.

  • Maintain linens dry and free of winkles, crumbs. Moisture exacerbates pruritus and augments risk of skin breakdown.

  • Raise lower extremities occasionally, if tolerated. Improves venous return. Decreses edema formation.

  • Restrict chair sitting to 2 hours at any one time. Pressure over sacrum may go beyond 100 mm Hg pressure during sitting. The pressure essential to close skin capillaries is approximately 32 mm Hg; any pressure higher than 32 mm Hg leads to skin ischemia.

  • Persuade sufficient nutrition and hydration:
    1. 2000 to 3000 kcal pre day (more if increased metabolic demands).
Fluid intake of 2000 ml per day unless contraindicated. Hydrated skin has lower risk of skin breakdown. Patients with restricted cardiovascular reserve may not be able to tolerate this much fluid.

  • Apply antibiotic ointment per protocol. Useful in avoiding local infection and decreasing risk of cranial infection.

  • Blisters are sterile natural dressings, leave blisters intact by wrapping in gauze, or applying a hydrocolloid or a vapor-permeable membrane dressing. Leaving them intact keeps the skin’s natural function as barrier to pathogens as the damaged area below the blister heals.

  • Cleanse open wounds or ulcers with hydrogen peroxide, boric acid, or povidone iodine (Betadine) solutions as indicated. Check distribution, size, depth, character, and drainage. Improvement or delayed healing reflects condition of tissue perfusion and effectiveness of treatments. Note: These patients are at higher risk of grave complications because of decreased resistance to infection and reduced nutrients for healing.

  • Consult dietitian as needed.

  • Utilize alternating pressure mattress, egg-crate mattress, waterbed, sheepskins, as needed. Decreases dermal pressure, increases circulation, and reduces risk of tissue ischemia or breakdown.

  • If patient is confined to bed:
    1. Persuade execution and posting of a turning schedule, limiting time in one position to 2 hours or less and modifying the schedule to patient’s routine and caregiver’s needs. Improves circulation and avoids unnecessary pressure on skin or tissues. Additionally, a schedule that does not hinder with the patient’s and caregivers’ activities is most expected to be followed.

    1. Encourage implementation of pressure-relieving devices commensurate with degree of risk for skin impairment:
For low-risk patients
Good-quality (dense, at least 5 inches thick) foam mattress overlay
For moderate risk patients
Water mattress, static or dynamic air mattress. In the home, a waterbed is a good alternative.
For high-risk patients or those with existing stage III or IV pressure sores (or with stage II pressure sores and multiple risk factors)
Low-air-loss beds (Mediscus, Flexicare, Kinair) or air-fluidized therapy (Clinitron, Skytron)

Educative (Edx)
  • Educate patient or caregiver/significant other the appropriate use and maintenance of pressure-relieving devices to be utilized at home.

  • Persuade ambulation if patient is able.

  • Persuade patient and/or caregiver/significant other to keep functional body alignment.

  • Persuade patient to prevent vigorous rubbing and scratching and to pat skin dry as an alternative for rubbing. Helps avoid skin friction or trauma to sensitive tissues.

  • Persuade use of lift sheets to move patient in bed and discourage patient or caregiver/significant other from raising head of bed frequently. These actions decrease shearing forces on the skin.

  • Persuade with repositioning on a regular schedule, even as in bed or chair, and active or passive ROM exercises as suitable. Repositioning decreases pressure on edematous tissues to promote circulation. Exercises improve circulation and enhance or keep joint mobility.

  • Propose utilization of knuckles if want to scratch is uncontrollable. Maintain fingernails cut short, give mittens or gloves on comatose patient or throughout hours of sleep. Suggest loose-fitting clothing. Offer soft cotton linens. Avoids patient from unintentionally injuring the skin, particularly while sleeping. Decreases potential for dermal injury.

  • Recommend wearing loose-fitting cotton garments. Avoids direct dermal irritation and improves evaporation of moisture on the skin.

  • Educate patient and caregiver the reason(s) of pressure ulcer development:
    1. Pressure on skin, particularly over bony prominences
    2. Incontinence
    3. Poor nutrition
    4. Shearing or friction against skin

1 comment:

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