Risk for Impaired Skin Integrity | Nursing Diagnosis for Sickle Cell Disease

Nursing diagnosis: risk for impaired Skin Integrity

Risk factors may include
Impaired circulation—venous stasis and vaso-occlusion; altered sensation
Decreased mobility, bedrest

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
Prevent dermal ischemic injury.
Display improvement in wound or lesion healing if present.
Risk Control
Participate in behaviors to reduce risk factors and skin breakdown.

Nursing intervention with rationale:
1. Reposition frequently, even when sitting in chair.
Rationale: Prevents prolonged tissue pressure where circulation is already compromised, reducing risk of tissue trauma and ischemia.

2. Inspect skin pressure points regularly for redness and provide gentle massage.
Rationale: Poor circulation may predispose to rapid skin breakdown.

3. Protect bony prominences with sheepskin, heel and elbow protectors, or pillows, as indicated.
Rationale: Decreases pressure on tissues, preventing skin breakdown.

4. Keep skin surfaces dry and clean and linens dry and wrinkle free.
Rationale: Moist, contaminated areas provide excellent media for growth of pathogenic organisms.

5. Monitor ischemic areas, leg bruises, cuts, and bumps closely for ulcer formation.
Rationale: Potential entry sites for pathogenic organisms. In presence of altered immune system, this increases risk of infection and delayed healing.

6. Elevate lower extremities when sitting.
Rationale: Enhances venous return, reducing venous stasis and edema formation.

7. Provide egg-crate, alternating air pressure, or water mattress.
Rationale: Reduces tissue pressure and aids in maximizing cellular perfusion to prevent dermal injury.

8. Provide wound care as indicated, such as cleansing and débriding open wounds and ulcers according to protocol.
Rationale: Improvement or delayed healing reflects status of tissue perfusion and effectiveness of interventions. Note: These clients are at increased risk of serious complications because of lowered resistance to infection and decreased nutrients for healing.

9. Prepare for and assist with hyperbaric oxygenation of ulcer sites.
Rationale: Maximizes oxygen delivery to tissues, enhancing healing.