Open Resources for Nursing (Open RN)
During a subjective assessment of a patient’s integumentary system, begin by asking about current symptoms such as itching, rashes, or wounds. If a patient has a wound, it is important to determine if a patient has pain associated with the wound so that pain management can be implemented. For patients with chronic wounds, it is also important to identify factors that delay wound healing, such as nutrition, decreased oxygenation, infection, stress, diabetes, obesity, medications, alcohol use, and smoking. See Table 10.6a for a list of suggested interview questions to use when assessing a patient with a wound.
If a patient has a chronic wound or is experiencing delayed wound healing, it is important for the nurse to assess the impact of the wound on their quality of life. Several studies have shown that patients with nonhealing wounds have a decreased quality of life. Reasons for this include the frequency and regularity of dressing changes, which affect daily routine; a feeling of continued fatigue due to lack of sleep; restricted mobility; pain; odor; and the side effects of multiple medications. The loss of independence associated with functional decline can also lead to changes in overall health and well-being. These changes include altered eating habits, depression, social isolation, and a gradual reduction in activity levels.
Table 10.6a Interview Questions Related to Integumentary Disorders
When performing an objective integumentary assessment on a patient receiving inpatient care, it is important to perform a thorough exam on admission to check for existing wounds, as well as to evaluate their risk of skin breakdown using the Braden Scale. Agencies are not reimbursed for care of pressure injuries received during a patient’s stay, so existing wounds on admission must be well-documented. Routine skin assessment should continue throughout a patient’s stay, usually on a daily or shift-by-shift basis based on the patient’s condition. If a wound is present, it is assessed during every dressing change for signs of healing. See Table 10.6b for components to include in a wound assessment. See Figure 10.22 for an image of a common tool used to document the location of a skin concern found during assessment.
Read more information about performing an overall integumentary assessment in the “Integumentary Assessment” chapter in Open RN Nursing Skills.
For additional discussion regarding assessing wounds, go to the “Assessing Wounds” section of the “Wound Care” chapter in Open RN Nursing Skills.
Table 10.6b Wound Assessment
Figure 10.22 Skin Concern Documentation
Figure 10.23 Purulent Drainage
See Table 10.6c for a comparison of expected versus unexpected findings on integumentary assessment.
Table 10.6c Expected Versus Unexpected Findings
Diagnostic and Lab Work
When a chronic wound is not healing as expected, laboratory test results can provide additional clues for the delayed healing. See Table 10.6d for a summary of lab results that offer clues to systemic issues causing delayed wound healing.
Table 10.6d Lab Values Associated with Delayed Wound Healing
Life Span and Cultural Considerations
Newborns and Infants
Newborn skin is thin and sensitive. It tends to be easy to scratch and bruise and is susceptible to rashes and irritation. Common rashes seen in newborns and infants include diaper rash (contact dermatitis), cradle cap (seborrheic dermatitis), newborn acne, and prickly heat.
Toddlers and Preschoolers
Because of high levels of activity and increasing mobility, this age group is more prone to accidents. Issues like lacerations, abrasions, burns, and sunburns can occur frequently. It is important to be highly aware of the potential for accidents and implement safety precautions as needed.
School-Aged Children and Adolescents
Skin rashes tend to affect skin within this age group. Impetigo, scabies, and head lice are commonly seen and may keep children home from school. Acne vulgaris typically begins during adolescence and can alter physical appearance, which can be very upsetting to this age group. Another change during adolescence is the appearance of axillary, pubic, and other body hair. Also, as these children spend more time out of doors, sunburns are more common, and care should be given to encourage sunscreen and discourage the use of tanning beds.
Adults and Older Adults
As skin ages, many changes take place. Because aging increases the loss of subcutaneous fat and collagen breakdown, skin becomes thinner and wrinkles deepen. Decreased sweat gland activity leads to drier skin and pruritus (itching). Healing is slowed because of reduced circulation and the inability of proteins and proper nutrients to arrive at injury sites. Hair loses pigmentation and turns gray or white. Nails become thicker and are more difficult to cut. Age or liver spots become darker and more noticeable. The number of skin growths increases and includes skin tags and keratoses. There is often delayed wound healing in older adults.
There are several NANDA-I nursing diagnoses related to patients experiencing skin alterations or those at risk of developing a skin injury. See Table 10.6e for common NANDA-I nursing diagnoses and their definitions.
Table 10.6e Common NANDA-I Nursing Diagnoses Related to Integumentary Disorders
A commonly used NANDA-I nursing diagnosis for patients experiencing alterations in the integumentary system is Impaired Tissue Integrity, defined as, “Damage to the mucous membrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament.”
To verify accuracy of this diagnosis for a patient, the nurse compares assessment findings with defining characteristics of that diagnosis. Defining characteristics for Impaired Tissue Integrity include the following:
A sample NANDA-I diagnosis in current PES format would be: “Impaired Tissue Integrity related to insufficient knowledge about protecting tissue integrity as evidenced by redness and tissue damage.”
An example of a broad goal for a patient experiencing alterations in tissue integrity is:
A sample SMART expected outcome for a patient with a wound is:
In addition to the interventions outlined under the “Braden Scale” section to prevent and treat pressure injury, see the following box for a list interventions to prevent and treat impaired skin integrity. As always, consult a current, evidence-based nurse care planning resource for additional interventions when planning patient care.
Selected Interventions to Prevent and Treat Impaired Skin Integrity ,,
Before implementing interventions, it is important to assess the current status of the skin and risk factors present for skin breakdown and modify interventions based on the patient’s current status. For example, if a patient’s rash has resolved, some interventions may no longer be appropriate (such as applying topical creams). However, if a wound is showing signs of worsening or delayed healing, additional interventions may be required. As always, if the patient demonstrates new signs of localized or systemic infection, the provider should be notified.
It is important to evaluate for healing when performing wound care. Use the following expected outcomes when evaluating wound healing:
If a patient is experiencing delayed wound healing or has a chronic wound, it is helpful to advocate for a referral to a wound care nurse specialist.
Read a sample nursing care plan for a patient with impaired skin integrity.
Drainage from a wound that is fresh bleeding.
Drainage from a wound that is clear, thin, watery plasma. It’s normal during the inflammatory stage of wound healing, and small amounts are considered normal wound drainage.
Serous drainage with small amounts of blood present.
Drainage that is thick; opaque; tan, yellow, green, or brown in color. New purulent drainage should always be reported to the health care provider.