Risk for impaired skin integrity related to prolonged immobility, poor skin turgor, poor circulation or altered sensation (use one)
Patient will maintain intact skin as evidenced by: no redness over bony prominences, and capillary refill less than 6 seconds over areas of redness.
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.