Susceptible to alteration in epidermis and/or dermis, which may compromise health

External Factors

Excessive moisture

Excretions

Humidity

Hyperthermia

Hypothermia

Inadequate caregiver knowledge about maintaining tissue integrity

Inadequate caregiver knowledge about protecting tissue integrity

Inadequate use of chemical agent

Pressure over bony prominence

Psychomotor agitation

Secretions

Shearing forces

Surface friction

Use of linen with insufficient moisture wicking property

Internal Factors

Body mass index above normal range for age and gender

Body mass index below normal range for age and gender

Decreased physical activity

Decreased physical mobility

Edema

Inadequate adherence to incontinence treatment regimen

Inadequate knowledge about maintaining skin integrity

Inadequate knowledge about protecting skin integrity

Malnutrition

Psychogenic factor

Self mutilation

Smoking

Substance misuse

Water-electrolyte imbalance

Individuals at extremes of age

Individuals in intensive care units

Individuals in long-term care facilities

Individuals in palliative care settings

Individuals receiving home-based care

Altered pigmentation

Anemia

Cardiovascular diseases

Decreased level of consciousness

Decreased tissue oxygenation

Decreased tissue perfusion

Diabetes mellitus

Hormonal change

Immobilization

Immunodeficiency

Impaired metabolism

Infections

Medical devices

Neoplasms

Peripheral neuropathy

Pharmaceutical preparations

Punctures

Sensation disorders

AUTHOR'S NOTE

Risk for Impaired Skin Integrity describes any dermatological condition that causes discomforts such as pruritus or irritation. A common irritant to the skin is urine or equipment.

The individual will demonstrate skin integrity free of injury (if able), as evidenced by the following indicators:

• Participates in risk assessment.
• Expresses willingness to participate in prevention of skin injury or irritation.
• Describes etiology and prevention measures.

Level 1 Fundamental Focused Assessment

Use a Formal Risk Assessment Scale to Identify Individual Risk Factors in Addition to Activity and Mobility Deficits (e.g., The Braden Scale)

Level 1 Fundamental Focused Interventions

Attempt to Modify Contributing Factors to Lessen the Possibility of Injuring the Skin Such as Incontinence of Urine or Feces

• Determine the etiology of the incontinence.
• Maintain sufficient fluid intake for adequate hydration (approximately 2500 mL daily, unless contraindicated)
• Check oral mucous membranes for moisture, and check urine specific gravity.
• Establish a schedule for emptying the bladder (begin with every 2 hours).
• If confused, determine what his or her incontinence pattern is and intervene before incontinence occurs.
• Explain the problem and secure his or her cooperation with the plan.
• When incontinent, wash the perineum with a liquid soap that does not alter skin pH.
• Apply a protective barrier to the perineal region (incontinence film barrier spray or wipes).
• Check frequently for incontinence when indicated.
• For additional interventions, refer to Impaired Urinary Elimination.

R:Maceration is a mechanism by which the tissue is softened by prolonged wetting or soaking. If the skin becomes waterlogged, the cells are weakened and the epidermis is easily eroded. Bowel incontinence is more damaging than urinary incontinence due to the additional digestive enzymes found in stool. Care must be taken to prevent excoriation (Norris 2019).

Immobility

Encourage range of motion exercises and weight-bearing mobility, when possible, to increase blood flow to all areas.

• Use repositioning schedule that relieves vulnerable area most often (e.g., if the vulnerable area is the back, the turning schedule would be left side to back, back to right side, right side to left side, and left side to back); post "turn clock" at bedside.
• Turn or instruct the individual to turn or shift weight every 30 minutes to 2 hours, depending on other causative factors and the ability of the skin to recover from pressure.
• Increase frequency of the turning schedule if any reddened areas that appear do not disappear within 1 hour after turning.
• Place the individual in a normal or neutral position with body weight evenly distributed. Use 30° laterally inclined position when possible.
• Keep the bed as flat as possible to reduce shearing forces; limit semi-Fowler's position to only 30 minutes at a time.
• Use enough personnel to lift the person up in bed or a chair rather than pull or slide skin surfaces.

R:Shear is a parallel force in which one layer of tissue moves in one direction and another layer moves in the opposite direction. If the skin sticks to the bed linen and the weight of the body makes the skeleton slide down inside the skin (as with semi-Fowler's positioning), the subepidermal capillaries may become angulated and pinched, resulting in decreased perfusion of the tissue (Norris, 2019).

Reduce Pressure Points

• Avoid foam donuts or inflatable rings because these increase the area of pressure.
• Alternate or reduce the pressure on the skin with an appropriate support surface.
• Suspend heels off the bed surface.
• Encourage the individual to wear a long-sleeved top and socks to reduce friction on elbows and heels.
• To reduce shearing forces, support the feet with a footboard to prevent sliding.
• Limit sitting time for high risk for dermal injury.
• Instruct the individual to lift self using chair arms every 10 minutes, if possible, or assist in rising up off the chair at least every hour, depending on risk factors present.
• Do not elevate the legs unless calves are supported to reduce the pressure over the ischial tuberosities.
• Pad the chair with pressure-relieving cushion.

Observe for Erythema and Blanching and Palpate for Warmth and Tissue Sponginess with Each Position Change

• Ears
• Elbows
• Trochanter
• Heels
• Ischia
• Sacrum
• Scapula
• Scrotum
• Do not rub reddened areas
• To avoid damaging the capillaries, do not perform massage

R:Pressure is a compressing downward force on a given area. If pressure against soft tissue is greater than intracapillary blood pressure (approximately 32 mm Hg), the capillaries can be occluded, and the tissue can be damaged as a result of hypoxia.

R:Friction is the physiologic wearing away of tissue. If the skin is rubbed against the bed linens, the epidermis can be denuded by abrasion.

Prevent Vitamin and Protein Malnourishment

• Consult a dietitian.
• Increase protein and carbohydrate intake to maintain a positive nitrogen balance; weigh per protocol.
• Ascertain that daily intake of vitamins and minerals is maintained through diet or supplements.
• See Imbalanced Nutrition: Less Than Body Requirements for additional interventions.

R:Adequate nutrition (protein, vitamins, minerals) is vital for healing wounds, preventing infection, preserving immune function, and minimizing the loss of strength.

Initiate Health Teaching, as Indicated

• Instruct on specific techniques to use at home to prevent pressure injuries.
• Teach the importance of good skin hygiene and optimal nutrition.
• Prior to transition, refer to a community nursing agency if additional assistance at home is needed.