Impaired Skin Integrity Nursing Care Plan: 2 Sample Plans and Interventions

Impaired skin integrity means the outer layers of the skin are damaged, such as from pressure, moisture, friction, or a wound. Clients who are immobile, incontinent, or poorly nourished are most at risk. Your priorities are relieving pressure, keeping skin clean and dry, supporting nutrition, and promoting healing.

A · AssessmentD · DiagnosisP · PlanningI · InterventionE · Evaluation

Each care plan below follows the nursing process (ADPIE).

CARE PLAN 1 · NURSING DIAGNOSIS

Impaired Skin Integrity

Related to

Prolonged pressure over bony areas
Moisture from incontinence or sweating
Friction and shear when moving in bed
Poor nutrition and low protein

As evidenced by

Redness that does not blanch over a bony area
Open area or blister on the skin
Broken skin with drainage

PLANNING · EXPECTED OUTCOMES

Short-term goals

Wound shows signs of healing such as smaller size and pink tissue within 1 week
No new areas of skin breakdown develop

Long-term goals

Wound is healed and the client keeps skin intact at home

ASSESSMENT

Skin from head to toe at least every shift, with focus on bony areas
Wound size, depth, drainage, color, and odor
Risk score using a tool such as the Braden Scale
Nutrition, weight, and albumin or prealbumin as ordered

INTERVENTIONS AND RATIONALES

INTERVENTION	RATIONALE
Reposition at least every 2 hours and use pressure-relieving surfaces	Shifting weight restores blood flow to the skin.
Keep the head of the bed at 30 degrees or lower unless contraindicated	A lower angle reduces sliding and shear.
Use a lift sheet to move the client up in bed	Lifting instead of dragging prevents friction and shear.
Clean skin promptly after incontinence and apply a moisture barrier	Moisture softens the skin and makes it break down faster.
Encourage protein, calories, and fluids, and consult the dietitian as ordered	Healing tissue needs protein and good hydration.

EVALUATION

Wound is getting smaller with healthy pink tissue
No new pressure areas appear
Client or family describes how to prevent skin breakdown

CARE PLAN 2 · NURSING DIAGNOSIS

Risk for Infection

Risk factors

Open wound
Moisture or stool near the wound
Poor circulation or nutrition

PLANNING · EXPECTED OUTCOMES

Short-term goals

Wound shows no signs of infection during the hospital stay

Long-term goals

Wound heals without infection

ASSESSMENT

Wound for increased redness, warmth, swelling, pain, odor, or pus
Temperature
WBC as ordered

INTERVENTIONS AND RATIONALES

INTERVENTION	RATIONALE
Use clean or sterile technique for wound care as ordered	This keeps germs out of the wound.
Change dressings as ordered and when soiled	Wet or dirty dressings hold bacteria against the wound.
Keep stool and urine away from the wound	Body waste carries bacteria that can infect the wound.

EVALUATION

Wound has no signs of infection
Client remains afebrile

Practice this in Head-to-Toe

Practice a full skin check and catch pressure injuries early.

Play Head-to-Toe

Quick answers

What does a stage 1 pressure injury look like?

Intact skin with redness that does not blanch when pressed. On darker skin, it may look purple or bluish, or feel warmer or firmer than the skin around it.

Why keep the head of the bed at 30 degrees or lower?

Higher angles cause the client to slide down, creating shear that damages deep tissue over the tailbone.

For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.