Quick answer: Impaired Skin Integrity is a NANDA-I nursing diagnosis describing altered epidermis, dermis, or both. A care plan for it follows the standard structure: assessment, diagnostic statement, measurable outcomes, interventions with rationales, and evaluation. The single most common mistake students make is confusing it with two neighbouring diagnoses — Risk for Impaired Skin Integrity, where no damage has occurred yet, and Impaired Tissue Integrity, where damage extends below the dermis. Getting that distinction right is most of the work.
This is an educational overview for nursing students and healthcare learners. Your facility’s own policies, wound care protocols and formulary always take precedence over any general guide, and wound assessment and treatment decisions sit with the responsible clinician.
Choosing the Right Diagnosis: The Three That Get Confused
Pick the wrong one and the rest of the care plan is wrong with it, because outcomes and interventions follow from the diagnosis.
| Diagnosis | Use when | Key feature |
|---|---|---|
| Risk for Impaired Skin Integrity | Skin is currently intact, but risk factors are present | A risk diagnosis has no defining characteristics and no “as evidenced by” — you cannot cite damage that has not happened. It is written in two parts, not three |
| Impaired Skin Integrity | Actual damage limited to the epidermis and/or dermis | Stage 1 and 2 pressure injuries, skin tears, superficial partial-thickness wounds, moisture-associated damage |
| Impaired Tissue Integrity | Damage extends deeper — subcutaneous tissue, muscle, fascia, tendon or bone | Stage 3 and 4 pressure injuries, full-thickness wounds. Skin integrity is the wrong diagnosis here |
A working rule: if you can see or probe below the dermis, it is Impaired Tissue Integrity. If the skin is unbroken and you are documenting risk factors rather than damage, it is the risk diagnosis. Note that unstageable pressure injuries and deep tissue injuries are generally handled as tissue integrity, since the depth is either obscured or known to be deeper than it appears.
Step 1: Assessment
Your assessment data becomes the “as evidenced by” of your diagnostic statement, so gather it before you write anything.
Subjective data
- Reports of pain, burning, itching or tenderness at the site, and pain on movement or repositioning
- Reported numbness or reduced sensation, which raises risk considerably
- Continence history, appetite and recent intake, and the patient’s own account of how the wound started
Objective data
- Wound characteristics: anatomical location, length, width and depth in centimetres, wound bed appearance (granulation, slough, eschar), undermining or tunnelling with clock-face position, exudate amount, colour and odour, and the condition of the surrounding skin
- Pressure injury stage, where applicable
- A validated risk score, most commonly the Braden Scale
- Mobility status, ability to reposition independently, and use of devices
- Nutritional markers — weight and weight change, intake, and albumin or prealbumin where available
- Perfusion and comorbidities — diabetes, peripheral arterial disease, immunosuppression, corticosteroid use, incontinence
- Signs of infection: increasing erythema, warmth, purulent exudate, odour, fever, rising white cell count, or a wound that has stopped progressing
Assessing darker skin tones
Worth its own note, because it is a recognised source of missed and late-stage diagnosis. Stage 1 pressure injury is classically described as non-blanchable erythema, but redness is difficult or impossible to see in darkly pigmented skin. Assess instead for a change in skin colour compared with surrounding tissue (which may appear purple, bluish or darker rather than red), and for differences in temperature, firmness, boggy or oedematous texture, and pain. Good lighting and moist touch assessment matter more here than visual inspection alone.
The Braden Scale
The most widely used pressure injury risk tool, and one you should be able to describe rather than just name.
It scores six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Five are scored 1 to 4 and friction and shear is scored 1 to 3, giving a total range of 6 to 23. Lower scores mean higher risk.
| Total score | Risk level |
|---|---|
| 19 to 23 | Not at risk |
| 15 to 18 | Mild risk |
| 13 to 14 | Moderate risk |
| 10 to 12 | High risk |
| 9 or below | Very high risk |
Two points examiners look for. First, the subscale scores matter more than the total — a patient scoring low specifically on moisture needs a different plan from one scoring low on mobility, even at the same total. Second, the tool supports clinical judgement rather than replacing it: a patient with an adequate total score but an existing wound is still high risk.
Step 2: Writing the Diagnostic Statement
An actual (problem-focused) diagnosis uses three parts — problem, related to, as evidenced by:
Impaired Skin Integrity related to prolonged pressure over a bony prominence and impaired mobility as evidenced by a 3 cm by 2 cm stage 2 pressure injury to the sacrum with a pink, moist wound bed and a Braden score of 12.
A risk diagnosis uses two parts only, because there is no evidence of damage to cite:
Risk for Impaired Skin Integrity related to immobility, urinary incontinence and inadequate nutritional intake.
Common errors to avoid: writing a medical diagnosis in the “related to” clause (say “impaired mobility”, not “related to stroke”); adding an “as evidenced by” to a risk diagnosis; and using vague related-to factors that no intervention can address.
Step 3: Outcomes and Goals
Outcomes must be measurable and time-bound, or you cannot evaluate them. Write what the patient will do or demonstrate, not what the nurse will do.
- Short-term: “The patient’s sacral wound will show no increase in size or depth, and no signs of infection, by the end of the shift.”
- Short-term: “The patient will be repositioned at least every two hours, documented on the turning schedule, over the next 24 hours.”
- Long-term: “The patient’s sacral wound will demonstrate progressive healing, evidenced by a reduction in surface area and increased granulation tissue, within 14 days.”
- Knowledge outcome: “The patient and caregiver will verbalise three pressure injury prevention strategies before discharge.”
- Prevention outcome: “The patient will remain free of new areas of skin breakdown throughout the admission.”
Step 4: Interventions With Rationales
The rationale column is where marks are won and lost. Every intervention needs a reason.
| Intervention | Rationale |
|---|---|
| Assess skin head to toe at least once per shift, focusing on bony prominences — sacrum, heels, ischial tuberosities, trochanters, occiput, elbows | Early identification allows intervention before damage progresses; these sites bear the highest interface pressure |
| Reposition at least every two hours in bed, and every hour if seated (or encourage small shifts every 15 minutes if able) | Relieves capillary pressure and restores perfusion. Seated patients generate higher interface pressures than those lying down |
| Use the 30-degree lateral position rather than 90 degrees when side-lying | Avoids placing body weight directly on the trochanter |
| Keep the head of the bed at 30 degrees or less unless clinically contraindicated | Higher elevation increases shear on the sacrum as the patient slides down |
| Use lifting devices, a slide sheet or two-person lift when moving the patient — never drag | Dragging generates friction and shear, which damage tissue independently of pressure |
| Provide a pressure-redistribution mattress or cushion appropriate to risk level | Distributes load over a greater surface area, lowering peak interface pressure |
| Keep skin clean and dry; use a pH-balanced cleanser and a barrier product where incontinence or exudate is present | Moisture macerates skin and markedly increases susceptibility to friction damage |
| Float the heels off the bed using a pillow under the calves, or heel offloading devices | The heel has minimal subcutaneous padding and is a very common injury site |
| Refer to dietitian; support adequate protein, calories, fluid and micronutrients | Protein-energy malnutrition impairs collagen synthesis and delays healing |
| Perform wound care and dressing changes per facility protocol, maintaining a moist wound environment | Moist wound healing supports epithelialisation; the dressing should match exudate level |
| Measure and document the wound at defined intervals, using consistent technique | Objective serial measurement is how you evaluate whether the plan is working |
| Manage pain, particularly before dressing changes and repositioning | Uncontrolled pain reduces cooperation with turning, which undermines the whole plan |
| Educate patient and caregivers on repositioning, skin checks and nutrition | Supports adherence after discharge, when supervision ends |
What not to do
- Do not massage over bony prominences or reddened areas. This was once taught and is now advised against, because it can cause further tissue damage in compromised skin.
- Do not use ring or donut-shaped cushions. They concentrate pressure around the ring and impair circulation to the enclosed area.
- Do not use hot water or harsh soaps, which strip the skin barrier.
- Do not reverse-stage a healing pressure injury. A stage 3 injury that improves is documented as a healing stage 3, not as a stage 2, because lost tissue is replaced by scar rather than by the original structures.
- Do not rely on turning alone in a high-risk patient without addressing moisture, nutrition and support surface.
Step 5: Evaluation and Documentation
Evaluation compares actual outcomes against the ones you wrote, and states the decision that follows: continue, modify, or resolve the plan.
- Goal met: “Wound surface area reduced from 6 cm² to 4 cm² over 14 days with increased granulation. Goal met; continue current plan.”
- Goal partially met: “No increase in wound size, but no reduction either. Goal partially met; plan modified — dietitian review requested and support surface upgraded.”
- Goal not met: “Wound increased in depth with new slough present. Goal not met; wound care team notified and plan revised.”
Documentation should record objective measurements rather than impressions, note the time and position of each reposition, and describe what was observed rather than judging it. “Wound bed 100 percent pink granulation, scant serous exudate, no odour” is documentation; “wound looks better” is not.
When to Escalate
- Signs of local or systemic infection — spreading erythema, purulent exudate, odour, fever, rising inflammatory markers
- Exposed bone, tendon or muscle, or a wound that probes to bone
- A wound that deteriorates, or fails to show any progress over two to four weeks of appropriate care
- Suspected deep tissue injury, or an unstageable wound requiring debridement decisions
- Rapidly spreading erythema with severe pain out of proportion to appearance, which requires urgent medical review
- Any new pressure injury acquired during admission, which is generally a reportable incident
Related reading on the skin conditions that can present alongside this: our guides to common skin rashes and skin barrier care.
Frequently Asked Questions
Impaired Skin Integrity is a NANDA-I diagnosis defined as altered epidermis, dermis, or both. It is written in three parts for an actual problem: the diagnosis, the related factors, and the evidence. For example: Impaired Skin Integrity related to prolonged pressure over a bony prominence and impaired mobility, as evidenced by a 3 cm by 2 cm stage 2 pressure injury to the sacrum.
Depth. Impaired Skin Integrity covers damage limited to the epidermis and dermis, which includes stage 1 and 2 pressure injuries and skin tears. Impaired Tissue Integrity covers damage extending into subcutaneous tissue, muscle, fascia, tendon or bone, which includes stage 3 and 4 injuries. The working rule is that if you can see or probe below the dermis, it is tissue integrity.
In two parts only, not three. A risk diagnosis has no defining characteristics because no damage has occurred yet, so it never carries an as evidenced by clause. Write it as: Risk for Impaired Skin Integrity related to immobility, urinary incontinence and inadequate nutritional intake. Adding evidence of damage to a risk diagnosis is one of the most common errors.
A validated pressure injury risk tool scoring six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Five are scored 1 to 4 and friction and shear 1 to 3, giving a total range of 6 to 23, where lower means higher risk. Commonly used bands are 15 to 18 mild, 13 to 14 moderate, 10 to 12 high, and 9 or below very high, with 18 or under often triggering a prevention protocol. The subscale pattern matters more than the total, since low moisture and low mobility need different plans.
At least every two hours when in bed, and roughly hourly when seated, since seated patients generate higher interface pressures. Patients able to shift their own weight should be encouraged to do so every 15 minutes or so. Use a 30-degree lateral position rather than 90 degrees, keep the head of the bed at 30 degrees or less where clinically possible to limit shear, and document the time and position of each turn.
No. Massage over bony prominences and reddened areas was once taught but is now advised against, because it can cause further damage to already compromised tissue. Ring or donut-shaped cushions should also be avoided, since they concentrate pressure around the ring and impair circulation to the enclosed area.
Non-blanchable erythema is hard or impossible to see in darkly pigmented skin, which contributes to missed and late-stage diagnosis. Assess instead for colour change relative to surrounding tissue, which may appear purple, bluish or simply darker rather than red, along with differences in temperature, firmness, boggy or oedematous texture, and reported pain. Good lighting and touch assessment matter more than visual inspection alone.
No. A stage 3 injury that improves is documented as a healing stage 3, not downgraded to a stage 2. Staging describes the maximum depth of tissue loss, and lost tissue is replaced by scar rather than by the original structures, so the wound never regains the anatomy that defined a lower stage.
Sources
- National Pressure Injury Advisory Panel (NPIAP), for pressure injury staging definitions.
- International Guideline: Prevention and Treatment of Pressure Ulcers/Injuries (EPUAP/NPIAP/PPPIA).
- Agency for Healthcare Research and Quality — Preventing Pressure Ulcers in Hospitals toolkit.
- NICE guideline CG179 — Pressure ulcers: prevention and management.
- MedlinePlus — Pressure sores.
- StatPearls — Pressure Injury, NCBI Bookshelf.
Last updated: August 2026. This article is educational content for nursing students and healthcare learners, not clinical guidance for treating a specific patient. Nursing diagnosis terminology, staging definitions and risk tools are periodically revised, and your institution’s policies, wound care protocols and formulary take precedence. Wound assessment, staging and treatment decisions sit with the responsible clinician.
