Patients who cannot reposition themselves should be turned in bed on a schedule at least every 2 hours. Repositioning and support of boney prominences Measurements of wounds should occur at least weekly to monitor for progress. Observed wounds should be monitored to ensure dressings are intact or that skin breakdown is not worsening, such as increased redness. Skin at risk for breakdown should be closely monitored at least once a shift. Inadequate or incorrect wound care delays healing and increases the risk for infection. Wound care differs depending on the type of skin breakdown, location on the body, and size of the wound. Perform wound care per guidelines and orders Nursing Diagnosis: Impaired skin integrity related to immobility as evidenced by stage 2 pressure ulcer to the sacrumĭesired outcome: Patient will not experience worsening of pressure ulcer Intervention Nursing Care Plans for Impaired Skin Integrity Nursing Care Plan 1 A photograph should be taken for baseline comparison. Wounds must be staged correctly including length, width, and depth with detailed descriptions of drainage, peri-wound area, odor, and any tunneling or undermining. Observed wound and skin breakdown requires accurate documentation in order to monitor the healing and effectiveness of interventions. Patients who are unable to ask for assistance to use the bathroom or are incontinent need frequent monitoring to keep skin dry and clean. Patients who may have adequate mobility but are under the use of restraints are also at risk.Ĭonsider incontinence or self-care deficit Patients who cannot walk or cannot shift their weight in a chair or bed are at a higher risk for skin breakdown. Monitor ambulation status and bed mobility Poor skin turgor, decreased sensations (nerve damage), and poor circulation (lack of blood flow assessed via palpation of pulse sites as well as observed by purplish or ruddy discoloration of lower legs) increase the risk of tissue damage. The lower the score, the higher the risk of tissue injury. A Braden Skin Assessment should be completed by the nurse with every new admission, though some facilities require it on every shift.Īssess skin turgor, sensation, and circulation The patient is scored on six categories: Sensory perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear. The Braden Scale is an evidence-based tool that predicts the risk for pressure injuries. Nursing Assessment for Impaired Skin Integrity InterventionĪ thorough head-to-toe skin assessment should be performed on admission, transfer between units, and once per shift to monitor and/or prevent skin breakdown. Patient will verbalize proper prevention of pressure injuries.Patient will demonstrate effective wound care.Patient will experience timely healing of wounds without complications.Patient will maintain intact skin integrity.Observed open areas or breakdown, excoriation. Changes to skin color (erythema, bruising, blanching).Numbness to affected and surrounding skin.Signs and Symptoms (As evidenced by) Subjective: (Patient reports) Disease processes ( diabetes, autoimmune disorders).Poor nutritional state ( obesity, emaciation, dehydration).It is important that nurses understand how to assess, prevent, treat, and educate patients on impaired skin integrity. When the skin is compromised due to cuts, abrasions, ulcers, incisions, and wounds, it allows bacteria to enter causing infections. The skin is the body’s outermost defense system that keeps pathogens from entering and causing illness.
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