Risk For Impaired Skin Integrity: Nursing Care Plan For Risk for Impaired Skin Integrity

Nursing Diagnosis

Risk for impaired skin integrity related to prolonged immobility, poor skin turgor, poor circulation or altered sensation (use one)

 



Objective

Patient will maintain intact skin as evidenced by: no redness over bony prominences, and capillary refill less than 6 seconds over areas of redness.

Intervention

Assess the following predisposing factors:

  • General condition of the client’s skin. Check bony prominences
  • Check patient’s awareness of sensation of pressure and ability to feel pain
  • Check patient’s nutritional status, such as weight and serum albumin levels.

Massage bony prominence to promote circulation and increase tissue perfusion

Clean and dry skin over bony prominences twice a day

In case powder is needed, use medical-grade cornstarch; avoid talc.

Do not burst blisters, wrap them in gauze, or apply a hydrocolloid (Duoderm, Sween-Appeal) or a vapor-permeable membrane dressing (Op-Site, Tegaderm).

Check bed linens and ensure they are straightened without creases, crumbs or particles

Don’t leave patients for so long on bedpan

Move patients gently as dragging them can cause shear forces to exact pressure on the skin

Changing unconscious patients 2 hourly

Ensure patients are getting adequate nutrition and hydration.

 


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