Nursing Care Plan Risk For Impaired Skin Integrity 321k4x

NURSING CARE PLAN Date/ Time/ CUES Shift Nov Objective: 28 2016 1) Prolonged lying on bed 73 2) Patient’s inability to turn to side to side without assistance 3) Scaly/flaky skin 4) Generalized Weakness

NEED N U T R I T I O N A L M E T A B O L I C P A T T E

NURSING DIAGNOSIS Risk for impaired skin integrity r/t prolonged bed rest and decreased tissue perfusion.

OBJECTIVE OF CARE At the end of the 8-hour shift, patient will maintain skin integrity.

NURSING INTERVENTION 1) Inspect skin, noting bony prominences, presence of edema, areas altered circulation/pigment ation, or obesity/emaciation.

RATIONALE

EVALUATION

Skin is at risk because of impaired peripheral circulation, physical immobility, and alterations in nutritional status.

Goal met. At the end of the 8-hour nursing care, patient’s skin remained intact.

2) Provide gentle massage around reddened or blanched areas.

Improves blood flow, minimizing tissue hypoxia.

3) Reposition patient every 2 hours.

Reduces pressure on tissues, improving circulation and reducing time any one area is deprived of full blood flow.

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4) Provide frequent skin care; minimize with moisture/excretions

Excessive dryness or moisture damages skin and hastens breakdown.

5) Provide alternating pressure

Reduces pressure to skin, may improve circulation.

6) Maintain adequate nutrition and hydration

Hydrated skin is less prone to break down.

7) Encourage use of lift sheet to move patient and discourage caregiver from elevating HOB repeatedly.

These measures reduce shearing forces on the skin.

8) Monitor skin condition at least once a day for color or texture changes, dermatological conditions, or

Systemic infection can identify impending problems early.

lesions. 9) Always keep linens of the bed and mattress wrinkle free.

10) Place a pillow or gauze on bony prominences when patient is lying on his back.

Keeping the bed wrinkle free lessens the probability of developing pressure sores. Placing a gauze or pillow will lessen the pressure in accumulating on the bony prominences.