Impaired Skin Integrity related to Impetigo

Impetigo is a skin infection caused by bacteria. It causes red sores that can break open, ooze fluid, and develop a yellow-brown crust. Usually the cause is staphylococcal (staph) but sometimes streptococcus (strep) can cause it, too. It's very common and affects mainly children. These sores can occur anywhere on the body but most often appear around the mouth and nose.

There are two types of impetigo:

bullous impetigo, which causes large, painless, fluid-filled blisters
non-bullous impetigo, which is more contagious than bullous impetigo and causes sores that quickly rupture (burst) to leave a yellow-brown crust

Symptoms of impetigo :

  • On the skin, especially around the nose or mouth. The sores begin as small red spots, then change to blisters that eventually break open. The sores are generally not painful, but they may be itchy.
  • That ooze fluid and look crusty. Sores often look like they have been coated with honey or brown sugar.
  • That increase in size and number. Sores may be as small as a pimple or larger than a coin.

To minimise the risk of impetigo spreading, it's also advisable to:
  • avoid touching the sores
  • wash your hands regularly
  • not share flannels, sheets or towels
  • keep children off nursery, playgroup or school until their sores have dried up


Nursing Diagnosis and Interventions

Impaired Skin Integrity related to lesions and mechanical injury (scratching the itchy skin)

Expected outcomes :
  • No injuries or lesions on the skin.
  • Good tissue perfusion.
  • A good skin integrity can be maintained (sensation, elasticity, temperature)
  • Able to protect skin and keep skin moist and natural treatments.

Interventions and Rational :

1. Keep clean skin, to keep them clean and dry.
Rational: the skin clean and dry, will reduce the spread or proliferation of bacteria.

2. Instruct the patient to use, loose clothing.
Rational: a loose shirt, shirt will reduce friction on the skin lesions.

3. Monitor skin color, the existence of redness.
Rational: to know the progression of the disease and the effectiveness of actions taken.

4. Cut nails and keep the client's hand hygiene.
Rational: the nail that will reduce the short and avoid scratching the impetigo lesion severity.

5. Bathe the patient with warm water and soap (antiseptic).
R: warm water will kill bacteria and reduce the rash. Anti-septic soap can reduce or kill the bacteria on the skin.

6. Give the knowledge of the client not to scratch the wound.
Rational: the knowledge of patients on the treatment process can accelerate the success of the nursing process.

7. Collaboration for the administration of topical antibiotics on the client.
Rational: topical antibiotic may discontinue or inhibit the growth of bacteria.

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