Nursing diagnosis: risk for impaired Skin Integrity
Risk factors may include
Altered metabolic state, circulation (anemia with tissue ischemia), and sensation (peripheral neuropathy)
Changes in fluid status; alterations in skin turgor—edema
Reduced activity, immobility
Accumulation of toxins in the skin
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Tissue Integrity: Skin and Mucous Membranes
Maintain intact skin.
Demonstrate behaviors and techniques to prevent skin breakdown or injury.
Nursing intervention with rationale:
1. Inspect skin for changes in color, turgor, and vascularity. Note redness and excoriation. Observe for ecchymosis and purpura.
Rationale: Indicates areas of poor circulation and early breakdown that may lead to decubitus formation and infection.
2. Monitor fluid intake and hydration of skin and mucous membranes.
Rationale: Detects presence of dehydration or overhydration that affects circulation and tissue integrity at the cellular level.
3. Inspect dependent areas for edema. Elevate legs, as indicated.
Rationale: Edematous tissues are more prone to breakdown. Elevation promotes venous return, limiting venous stasis and edema formation.
4. Change position frequently, move client carefully, pad bony prominences with sheepskin, and use elbow and heel protectors.
Rationale: Decreases pressure on edematous, poorly perfused tissues to reduce ischemia.
5. Provide soothing skin care, restrict use of soaps, and apply ointments or creams such as lanolin or Aquaphor.
Rationale: Baking soda and cornstarch baths decrease itching and are less drying than soaps. Lotions and ointments may be desired to relieve dry, cracked skin.
6. Keep linens dry and wrinkle free.
Rationale: Reduces dermal irritation and risk of skin breakdown.
7. Investigate reports of itching.
Rationale: Although dialysis has largely eliminated skin problems associated with uremic frost, itching can occur because the skin is an excretory route for waste products, such as phosphate crystals associated with hyperparathyroidism in ESRD.
8. Recommend client use cool, moist compresses to apply pressure to, rather than scratch, pruritic areas. Keep fingernails short; encourage use of gloves during sleep, if needed.
Rationale: Alleviates discomfort and reduces risk of dermal injury.
9. Suggest wearing loose-fitting cotton garments.
Rationale: Prevents direct dermal irritation and promotes evaporation of moisture on the skin.
10. Provide foam or flotation mattress.
Rationale: Reduces prolonged pressure on tissues, which can limit cellular perfusion, potentiating ischemia and necrosis.