Nursing care
Impaired skin integrity nursing diagnosis: actual, risk for, or tissue integrity
Written and reviewed by Nicole Ramirez, BSN, RN, CMSRN · 4 min read · Updated November 2026
Short answer
Impaired skin integrity is a nursing diagnosis for damage to the outer layers of skin, such as a stage 2 pressure injury, a skin tear or moisture damage. It is related to pressure, moisture, shear, friction or poor nutrition and evidenced by the wound you see. If the skin is still intact but the patient is immobile, write risk for impaired skin integrity instead.
What causes the damage and how nursing removes each cause
Under NANDA-I, this label means the epidermis, the dermis or both are altered. MSD Manuals names immobility, undernutrition, incontinence, impaired sensation and age over 65 as major risks. The Braden Scale scores six areas: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Each area points to an intervention.
| Related factor | As evidenced by | Nursing intervention | Rationale |
|---|---|---|---|
| Pressure from immobility | Shallow open area or blister over the sacrum or heel | Reposition at least every 2 hours, side lying at 30 degrees, offload heels, pressure-redistributing surface | Unrelieved pressure over bone starves tissue of blood |
| Shear and friction | Damage where the patient slides down in bed | Keep head of bed elevation low, lift with a sheet rather than drag | Sliding stretches deeper tissue against the skin |
| Moisture from incontinence | Red, macerated skin in the perineum or folds | Clean promptly after each episode, use moisture-wicking pads, apply barrier products per policy | Wet skin breaks down faster |
| Poor nutrition | Low intake, weight loss | Dietitian referral, encourage protein and fluids | MSD Manuals stresses protein for wound healing |
| Wheelchair sitting | Damage over the ischial area | Teach weight shifts every 15 to 20 minutes | Short pressure breaks protect sitting areas |
Skin integrity or tissue integrity: depth decides
The taxonomy separates damage limited to the epidermis and dermis from damage that reaches deeper structures such as fascia, muscle, bone or mucous membranes. Many programs therefore use impaired skin integrity for a stage 2 pressure injury or a skin tear, and impaired tissue integrity for a stage 3 or 4 wound. MSD Manuals describes stage 4 as full thickness loss that exposes muscle or bone.
Stage 1 sits awkwardly: the skin is intact but shows nonblanchable redness. Check your program's guidance; many treat it as actual damage needing skin integrity interventions, while others write risk. The trap on care plan assignments is writing impaired skin integrity for a deep sacral wound with exposed bone, which understates the problem.
Writing the actual and the risk version for an immobile patient
Actual, hypothetical 82-year-old woman after a stroke: Impaired skin integrity related to prolonged pressure and moisture from incontinence as evidenced by a 2 cm by 3 cm partial thickness open area over the sacrum with a pink wound bed and no slough. Measurements and wound bed description let the next nurse judge progress.
Risk version, her roommate with intact skin: Risk for impaired skin integrity related to immobility and urinary incontinence. Some programs write the factors after as evidenced by; there are no signs to list either way. The goal is intact skin over bony prominences at every shift check, which the nurse verifies by inspecting heels, sacrum, hips and elbows.
Wound care choices that tell an evaluator you understood it
MSD Manuals describes keeping the wound moist, not dry, using dressings suited to the wound and cleaning with normal saline. An answer that suggests leaving a pressure injury open to air to dry it out contradicts that guidance. Pressure relief comes first: no dressing heals a wound that is still being sat or lain on.
MedlinePlus advises daily head to toe skin checks, keeping the bed at less than a 30 degree angle to prevent sliding, and padding between body parts that press together. Evaluate by comparing measurements and wound bed appearance over time, and report any wound that grows, gains slough or drains cloudy fluid.
Sources and further reading
Pressure Injuries - MSD Manual Professional Edition. Risk factors; Braden Scale categories; repositioning at least every 2 hours; 30 degree side lying; minimal head of bed elevation; stage 1 and stage 4 descriptions; moist wound environment; saline cleansing; protein for healing.
Preventing pressure injuries: MedlinePlus Medical Encyclopedia. Daily skin checks; moisture management; wheelchair weight shifts every 15 to 20 minutes; bed under 30 degrees; padding between body parts.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our med-surg practice questions are the closest set to what this page covers.
One question from the med-surg set
A client with chronic obstructive pulmonary disease has an oxygen saturation of 88% on 2 L/min via nasal cannula and is alert with no distress. What should the nurse do first?
Rationale
In COPD a saturation of 88–92% is the therapeutic target, not an emergency, and this client is alert with no distress. The first action is the independent nursing intervention that is least invasive and most likely to help: sit them up and reassess. Turning the oxygen up to 6 L/min risks blunting the hypoxic drive, and calling rapid response or drawing an ABG escalates ahead of an assessment you have not finished.
Answer: B
Common questions
What is impaired skin integrity related to?
Pressure from immobility, shear and friction, moisture from incontinence or sweat, poor nutrition, reduced sensation, older age, edema and medical devices pressing on skin. Name the factors you can act on.
How do you write risk for impaired skin integrity related to immobility as evidenced by?
Because the skin is intact, there are no signs. Write the label and risk factors: risk for impaired skin integrity related to immobility, incontinence and low protein intake. Some programs place the factors after as evidenced by; follow your rubric.
What are nursing interventions for impaired skin integrity?
Reposition at least every 2 hours, use pressure-redistributing surfaces, offload heels, keep skin clean and dry, limit head of bed elevation, lift rather than drag, support nutrition, keep wounds moist with appropriate dressings, and measure wounds regularly.
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