Risk for Impaired Skin Integrity: Nursing Goals and Interventions

Risk For Impaired Skin Integrity Related To Skin Contamination With Feces
Impaired Skin Integrity Related To Wound
Risk For Impaired Skin Integrity Related To Nasal Cannula
Short Term Goal For Impaired Skin Integrity
Nursing Care Plan For Impaired Skin Integrity Related To Pressure Ulcer
Impaired Skin Integrity Related To Diabetes
Impaired Skin Integrity Related To Cellulitis
Impaired Skin Integrity Related To Infection


Nursing Objective:
Patient’s skin will remains intact within …..(indicate time frame/throughout the period of hospitalization.

Nursing Intervention:

1. Assess general condition of skin so as to know the extent of required care and create a baseline data for evaluation

2. Assess skin over bony prominences where the risk of skin breakdown is greatest
3. Assess patient’s awareness of sensation or pressure as decreased sensation or pressure on affected part can make client unaware of ischemic pain in the affected part.
4.Regularly conduct skin care by gently massaging surroundings of affected area to promote circulation and increase tissue perfusion
5.Change patient’s position every 4 hour
6.Increase intake of protein and vitamins to replace worn out tissues
7.Increase hydration to improve circulation and skin turgor

Evaluation
Patient skin was intact after…… of Nursing intervention


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.