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CHAPTER 32 Skin Integrity & Wound Healing
tissue warmth, or drainage observed during care of the patient. ■ Turning and position changes. You must provide the UAP with the times for the turning and instructions for how they should position the patient at each turn. Turning and movement prevent tissue damage from ischemia, thereby preventing pressure injury. NURSING DIAGNOSIS/ANALYZING CUES The following nursing diagnoses are appropriate for patients who are at risk for skin breakdown or for patients who have wounds: ■ Risk for Impaired Skin Integrity is appropriate for patients who have one or more risk factors for skin breakdown (e.g., immobility, incontinence, extremes of age, impaired circulation, impaired sensation, under- nutrition, emaciation). Use a risk assessment tool (e.g., Norton or Braden scale) to evaluate the patient’s risk. ■ Impaired Skin Integrity is appropriate for patients who have experienced damage to the epidermis or dermis—for example, patients who have superficial wounds or a stage 1 or 2 pressure injury. ■ Impaired Tissue Integrity is appropriate for patients with wounds that extend into the subcutaneous tis- sue, muscle, or bone. Use this diagnosis for patients with deep wounds or a stage 3 or 4 pressure injury. ■ Risk for Impaired Tissue Integrity is appropriate for patients with Impaired Skin Integrity who are at risk for delayed healing. For example, Mr. Harmon (Meet Your Patient) has a stage 1 pressure injury but is at risk for further progression of the injury because of his age, his nutritional state, and the presence of another wound. Skin problems and wounds can be the etiology for other nursing diagnoses as well, for example: ■ Risk for Infection is an appropriate diagnosis if the patient has a traumatic wound or is immunosup- pressed, undernourished, or immobile. ■ Pain is a diagnosis that may be used for patients who are experiencing discomfort from the wound or from the treatments required to heal the wound. ■ Disturbed Body Image should be used if the patient is experiencing distress about the wound. Consider this diagnosis even if the patient is expected to make a complete recovery. Some patients experience extreme distress about wounds. You will certainly want to con- sider this diagnosis if the patient experiences an injury that is expected to result in disfigurement. PLANNING/PRIORITIZING HYPOTHESES AND GENERATING SOLUTIONS Examples of associated Nursing Outcomes Classification (NOC) standardized outcomes for skin and tissue integrity diagnoses include the following: Infection Immobility Consequences: Physiological
Nutritional Status: Food & Fluid Intake Tissue Integrity: Skin & Mucous Membranes Wound Healing: Secondary Intention
Individualized goals/outcome statements should address the need to maintain intact skin or heal the wound. For patients who have a diagnosis of Risk for Impaired Skin Integrity, you might write a goal such as the following: Maintains intact skin throughout treatment, as evidenced by good skin turgor with no erythema, edema, or breaks in the skin. For patients who have a wound (actual Impaired Skin Integrity or Impaired Tissue Integrity), you might write a goal such as the following: Wound will heal by May 1, as evidenced by a progressive decrease in the size of the wound, a decrease in drain- age from the wound, improvement in the condition of the surrounding skin, and no evidence of infection (ery- thema, purulent drainage, or odor). IMPLEMENTATION/TAKING ACTION Examples of Nursing Interventions Classification (NIC) standardized interventions for skin and tissue integrity problems include the following: Bedrest Care Nutrition Management Infection Protection Positioning Pressure Injury Prevention Wound Care Pressure Management Wound Irrigation Skin Surveillance Specific nursing activities directed at maintaining skin integrity or healing wounds focus on preventing and treating pressure injuries (see Example Client Condition: Pressure Injury) and other chronic wounds, providing wound care, and applying heat and cold therapies. What Wound Care Competencies Do I Need? Care planning to meet the complex, individualized needs of a patient with a chronic wound involves the entire multidisciplinary team (e.g., dietitians, infec- tion control specialist, wound specialist). Your wound assessment will guide your choice of interventions, which depend on the nature of the wound. Consider these two examples: ■ A patient with a diabetic foot ulcer must have all the pressure taken off that area because every step traumatizes healing tissues. The appropriate dressing must be selected; in addition, this patient will need to wear a special shoe that is specially made for patients with neuropathy. ■ Patients with a venous stasis ulcer commonly wear compression garments (e.g., elastic hose, stocking, or multilayer compression wrap). These provide contin- uous pressure to the veins, which improves venous
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