Care Plan for nursing diagnosis: Impaired Skin Integrity

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I need some help with a care plan I am doing. The diagnosis is impaired skin integrity r/t excretions and/or excretions. The pt has been an inpatient for several months. She originally was admitted for fistula repair, incisional hernia repair with mesh insertion. She also has a colostomy. Her abdomen is still open and healing and has 2 pouches which have been leaking stool, which is where the dx comes from. She has been on TPA feedings with only clear liquid po. She just started solid food & ensure po.

I have several nursing interventions with rationales but need more. So far I have: teach skin & wound assessment to monitor for infections & complications; individualize plan according to pts skin condition & preferences; teach pt why a specific treatment has been selected; assess the nutritional status; obtain consult with wound/ostomy specialist; minimize the exposure of skin to moisture; encourage consuming Ensure to increase protein & therefore skin healing; monitor lab values; and use careful sterile technique.

Apparently there are a lot of interventions that I have missed. I have been working on this for a while and am getting brain freeze I guess because I feel like I'm hitting a brick wall and can't think of any more. Any help would be greatly appreciated!!!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

I had to put a diagnostic statement together based on what you posted. . .impaired skin integrity r/t excretions and/or excretions secondary to incisional hernia repair with mesh insertion aeb open abdominal wound.

Your nursing diagnosis is incorrect. Impaired skin integrity is only used for wounds that only go as deep as the epidermis and heal in a week. Once the subcutaneous tissue is involved,
impaired tissue integrity is the diagnosis that needs to be used. When a surgeon cuts into the body to repair a hernia, there is impaired tissue integrity. This wound is healing by second intention (from the inside out) and it will take months for this to finally heal and close over.

What do you mean by and/or excretions? This is a problem, so you know what the cause of the problem is or you don't. Your aeb (evidence of the problem) should be a description of this open wound, measurements of it and any drainage.

Actually, a better diagnosis to use, if I understood your post, is
delayed surgical recovery.

Since you really didn't list the evidence that supported the diagnosis I can see why you don't seem happy with your interventions. You need to know what you are focusing your treatment (nursing interventions) on. So, make a list of what it is that is the evidence that proves the diagnosis exists. Interventions are of 4 types and address the symptoms (evidence) that support the diagnosis:

Assess/monitor/evaluate/observe (to evaluate the patient's condition)

Care/perform/provide/assist (performing actual patient care)

Teach/educate/instruct/supervise (educating patient or caregiver)

Manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)
----------------------------------------------

If I classify the interventions you listed into the 4 types, this is what they classify to:

assess/monitor/evaluate/observe (to evaluate the patient's condition)
assess the nutritional status - your diagnosis is impaired skin integrity. Where is your assessment of the evidence of the impaired skin?
Monitor lab values - what labs relate to impaired skin integrity?
[*]care/perform/provide/assist (performing actual patient care)

Minimize the exposure of skin to moisture - are you talking about this incisional hernia repair? Why does it need to be free of moisture? Are you referring to the skin or the open hole that is taking forever to heal? Is there any drainage?

Use careful sterile technique - of what procedure(s)?
Encourage consuming ensure to increase protein & therefore skin healing.

There should be interventions for the wound care procedures stating exactly how and when the dressing changes are to be done, how often assessments of the wound are to be done and documented, that ensure supplementation is to be given to the patient __ times a day, vitamin c supplementation given to help healing, a high protein diet if not contraindicated to help healing.
[*]teach/educate/instruct/supervise (educating patient or caregiver)

Teach skin & wound assessment to monitor for infections & complications - you have to be specific. Teach the signs and symptoms of wound infection, the signs and symptoms of specific complications teach pt why a specific treatment has been selected - makes no sense.

  • Obtain consult with wound/ostomy specialist - this should have already been done. Notify physician if there is any abnormal lab result
  • Individualize plan according to pts skin condition & preferences - this sounds like an instruction from your school assignment or something that was copied from a care plan book.
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That is the nursing diagnosis that my instructor wants me to use. Tissue integrity makes a lot more sense than skin integrity though. Delayed surgical healing would be optimal but I turned it in already and am doing revisions and don't really want to start all over. I didn't post the info from my assessment because I wanted to keep the post as short as possible and it was getting pretty long. I think I'm going to add things about re-positioning, ambulation and dressings. Some of the suggestions she gave me I thought that I had already addressed but I think I'm going to have to talk to her directly and see specifically what she's looking for and what I seem to be missing. Thanks a lot for you input though. I appreciate any help/advise you can give me!!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Your post was getting long? I spend hours putting together my replies to these questions.

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Well, I mean that I didn't want my post to seem like it was too long (not that I didn't want to spend more time on it) so I tried to condense it by not adding all of my assessment info in it. I was thinking about what nursing interventions to write up for her based on the assessment info that I did put down.

I am sure that you do spend hours responding to people....your replies are very informative and help a lot!!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

I need the information in order to give back a helpful reply. Unfortunately, some students think they are somehow violating the patient's confidentiality which is not true. In order to logically care plan, the assessment information is of critical importance not only for the diagnosis, but also for developing the interventions as well. When this information isn't posted is when I know that students do not understand the care planning process.

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This is fascinating! I feel as if I am working on my Care Plan presentation for the same exact patient.

One of my top 3 diagnosis (but not #1) is related to her leaking ostomies (ileostomy & urostomy), as well her immobility and the impaired skin integrity resulting. Her ostomies leak because she is such a tiny thing and has had such damage to her abdomen there really isn't enough area available for the appliances to seal properly. Her abdominal wound was healed over with the aid of a skin graft, still pink but intact. She currently has a Stage 2 ulcer on her sacrum and several red areas (not yet staged) on her scapula and down her spine) I think skin integrity is correct because I am concerned with the excoriation involved with her ostomy leakage and with the development of pressure ulcers R/T her immobility.

Are these two different nursing diagnosis? If I stick with the ostomy leakage only, what is an appropriate R/T factor? Impaired skin integrity r/t ostomy leakage? Impaired skin integrity r/t excretions secondary to in fitting ostomy appliances? I like the ostomy leakage because I watched it develop into a serious problem over the course of three weeks. When I met her, she had a rash covering the area in between stoma's which we used Calzine ointment on when changing/emptying bags. The final week of clinical, she was assigned to another student but we saw that these areas in between her two functioning ostomies and a third, non functioning stoma; had become totally excoriated. The nurses were now keeping the appliances off, and had placed 4X4 gauze over each stoma with regular changes.

What your best opinion on path to go with this?

I do appreciate any thoughts!

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Specializes in med/surg, telemetry, IV therapy, mgmt.
SiennaGreen said:
This is fascinating! I feel as if I am working on my Care Plan presentation for the same exact patient.

One of my top 3 diagnosis (but not #1) is related to her leaking ostomies (ileostomy & urostomy), as well her immobility and the impaired skin integrity resulting. Her ostomies leak because she is such a tiny thing and has had such damage to her abdomen there really isn't enough area available for the appliances to seal properly. Her abdominal wound was healed over with the aid of a skin graft, still pink but intact. She currently has a Stage 2 ulcer on her sacrum and several red areas (not yet staged) on her scapula and down her spine) I think skin integrity is correct because I am concerned with the excoriation involved with her ostomy leakage and with the development of pressure ulcers R/T her immobility.

Are these two different nursing diagnosis? If I stick with the ostomy leakage only, what is an appropriate R/T factor? Impaired skin integrity r/t ostomy leakage? Impaired skin integrity r/t excretions secondary to in fitting ostomy appliances? I like the ostomy leakage because I watched it develop into a serious problem over the course of three weeks. When I met her, she had a rash covering the area in between stoma's which we used Calzine ointment on when changing/emptying bags. The final week of clinical, she was assigned to another student but we saw that these areas in between her two functioning ostomies and a third, non functioning stoma; had become totally excoriated. The nurses were now keeping the appliances off, and had placed 4X4 gauze over each stoma with regular changes.

What your best opinion on path to go with this?

I do appreciate any thoughts!

The related factor for the Impaired Skin Integrity needs to explain the cause (etiology) of the impairment. Leakage of secretions from the stoma that cause the skin to break down is a process of maceration. Maceration is a term that means "the dissolution of skin". The moisture as well as the electrolyte composition from the secretions weakens the skin so that friction or sheering forces against the skin causes it to be torn away. There may also be enzymes in the secretions that are leaking from the stoma that are destructive to the tissue. Then, in as few words as possible make them your related factor. Some suggestions on how to word this are:

  • Impaired Skin Integrity R/T moisture and intestinal secretions
  • Impaired Skin Integrity R/T irritation due to bowel secretions

Impaired Tissue Integrity is used when ulcers get to Stage III and IV.

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Thanks so much!

I think I'll stick with Impaired skin integrity r/t irritation due to bowel secretions. I also read somewhere else r/t ostomy effluence.

I appreciate your insight!

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