SKIN INTEGRITY IMPAIRMENT (54)    NUPA ASSESSMENT PROBLEMS (1927.2)

Name Value
PROBLEM SKIN INTEGRITY IMPAIRMENT
PLAN
  • As appropriate, educate the patient/family to change the patient's position every two hours, the importance of keeping the skin clean and dry, the importance of adequate food and fluid intake, and the procedure for dressing changes/skin care.
  • Assess the skin on admission and at each shift.
  • Collaborate with interdisciplinary team members, as needed.
  • Document history of skin breakdown.
  • Keep the skin clean and dry. Use barrier ointments to protect skin.
  • Other:
  • Perform wound treatments, as ordered. Document the wound size, appearance, amount of drainage, and the wound care treatments performed.
  • Reposition patient every two hours and PRN, preventing sheering and protecting bony prominences from pressure.
DESIRED OUTCOME
Damage to the epidermal and dermal tissue. For example cellulitis, 

1 NANDA International (2005). Nursing Diagnoses: Definitions & 
Classification 2005-2006. Philadelphia: Author.
2Carpenito, L. J. (2000). Nursing Diagnosis: Application to Clinical 
Practice (8th ed.). Philadelphia: Lippincott
3Wilkinson, J. M. (2005) Nursing diagnosis handbook (8th ed). Upper 
Saddle River, NJ: Prentice Hall. 
venous stasis changes, falls and other injury, and Stage I, II, and III 
pressure sores.  (For Stage IV Pressure Sores or surgical incisions see 
Tissue Integrity, Impaired.) 1, 2

Related To: Bacterial, viral, or fungal infections, diabetes, nutritional 
alterations, mechanical irritants, treatment related injury (restraints, 
NGT, traction), excretions, noxious chemical agents. 1, 2
References: 
ACTIVE YES