![]() ![]() If skin is redden or swollen, then the area must be massaged every 2 hours to help stimulate blood flow.ĥ. Use pressure-lowering devices like foam cushions, alternating pressure mattresses, kinetic beds and pillows, when indicated.Ĥ. For example, prevent the heels from touching the bed all the time.ģ. The client must be positioned so that the skin is not exposed to constant pressure all the time. Prolonged pressure on bony prominences compromises blood flow, leading to skin ischemia.Ģ. Unless contraindicated, the client must be turned at a minimum of 2-3 hours. Monitor for signs of infection like pain, fever, foul discharge, redness or pus collection. If skin impairment is present, it must be staged.Ĥ. Photos should be obtained to prevent potential litigation.ģ. The skin should be examined for redness, pallor, edema and open sore. Assess the high-risk areas like bony prominences (elbows, sacrum, heels). Assess client’s risk of skin breakdown on admission using the available risk assessment tools like the Braden and Knoll assessment scale.Ģ. Regaining mobility Nursing interventions and rationale for each interventionġ. Absence of inflammation such as redness, swelling and edemaħ. Turn patient every few hours to prevent constant pressureĤ. Physiological: Poor dietary habits diminished appetite, inadequate dentition insufficient fluid intake and dehydration can prevent wounds from healing Nursing OutcomesĢ. A stoma may be poorly functioning and lead to leakage of fecal material on skinĥ. Client may also have severe itching, which can lead to excoriations and breakdown of skin. Prolonged sleeping or sitting in one position is probably the most common cause of skin breakdown. This can be a cast, splint, physical restraints or poor use of an ambulatory device. Mechanical: Anything that applies pressure on skin can lead to breakdown. Pharmacological: Use of certain drugs like sedative, neuromuscular blockers can lead to immobility in one position and lead to pressure soreĤ. Inability to sense pressure or pain is a common cause of pressure sores or open wounds.ģ. Psychological: Client may have mental illness, be delirious and may be sedated or restrained for a prolonged time, which can lead to pressure on skin. ![]() The constant pressure on bony prominences eventually leads to breakdown of skin.Ģ. Functional: Immobility is the primary cause. Related Factors (Impaired skin integrity related to):ġ. Defining Characteristics:ģ) denuded skin that may be accompanied by erythema, edema and dischargeĥ) the adjacent skin will be fragile and edematousĦ) depth of the tissue breakdown not fully assessed visuallyħ) discharge may vary from serous fluid to foul smelling, if there is an infection. NANDA-I Definition for Impaired skin integrity :Īltered epidermis and/or dermis. The epidermis is not intact and layers below the skin like the dermis and bone may be visible. Skin integrity may also be broken as a result of shearing or friction injury. Impaired skin integrity: breakdown in skin primarily due to impaired blood supply as a result of prolonged pressure on the tissue. Nursing care plan for Impaired skin integrity This nursing care plan contains the basic elements that defines this Nanda nursing diagnosis and the nursing interventions that could be taken as a nurse to make a nursing care plan for a patient with this nursing diagnosis. These are the important elements needed to make a nursing care plan for impaired skin integrity. ![]()
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