Impaired Skin Integrity — AIDS

Nursing Diagnosis: Skin Integrity, impaired, actual and/or risk for

Risk factors may include

• Decreased level of activity/immobility, altered sensation, skeletal prominence, changes in skin turgor
• Malnutrition, altered metabolic state

May be related to (actual)

• Immunologic deficit: AIDS-related dermatitis; viral, bacterial, and fungal infections (e.g., herpes, Pseudomonas, Candida); opportunistic disease processes (e.g., KS)
• Excretions/secretions

Possibly evidenced by

• Skin lesions; ulcerations; decubitus ulcer formation

Desired Outcomes

• Be free of/display improvement in wound/lesion healing.
• Demonstrate behaviors/techniques to prevent skin breakdown/promote healing.

Nursing Interventions	Rationale
Assess skin daily. Note color, turgor, circulation, and sensation. Describe/measure lesions and observe changes.	Establishes comparative baseline providing opportunity for timely intervention.
Maintain/instruct in good skin hygiene, e.g., wash thoroughly, pat dry carefully, and gently massage with lotion or appropriate cream.	Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to dry/fragile skin. Massaging increases circulation to the skin and promotes comfort. Note:Isolation precautions are required when extensive or open cutaneous lesions are present.
Reposition frequently. Use turn sheet as needed. Encourage periodic weight shifts. Protect bony prominences with pillows, heel/elbow pads, sheepskin.	Reduces stress on pressure points, improves blood flow to tissues, and promotes healing.
Maintain clean, dry, wrinkle-free linen, preferably soft cotton fabric.	Skin friction caused by wet/wrinkled or rough sheets leads to irritation of fragile skin and increases risk for infection.
Encourage ambulation/out of bed as tolerated.	Decreases pressure on skin from prolonged bedrest.
Cleanse perianal area by removing stool with water and mineral oil or commercial product. Avoid use of toilet paper if vesicles are present. Apply protective creams, e.g., zinc oxide, A & D ointment.	Prevents maceration caused by diarrhea and keeps perianal lesions dry. Note: Use of toilet paper may abrade lesions.
File nails regularly.	Long/rough nails increase risk of dermal damage.
Cover open pressure ulcers with sterile dressings or protective barrier, e.g., Tegaderm, DuoDerm, as indicated.	May reduce bacterial contamination, promote healing.
Provide foam/flotation/alternate pressure mattress or bed.	Reduces pressure on skin, tissue, and lesions, decreasing tissue ischemia.
Obtain cultures of open skin lesions.	Identifies pathogens and appropriate treatment choices.
Apply/administer topical/systemic drugs as indicated.	Used in treatment of skin lesions. Use of agents such as Prederm spray can stimulate circulation, enhancing healing process. Note: When multidose ointments are used, care must be taken to avoid cross-contamination.
Cover ulcerated KS lesions with wet-to-wet dressings or antibiotic ointment and nonstick dressing (e.g., Telfa), as indicated.	Protects ulcerated areas from contamination and promotes healing
Refer to physical therapy for regular exercise/activity program.	Promotes improved muscle tone and skin health.