PRIORITY NURSING DIAGNOSIS
Impaired skin integrity r/t impaired circulation AEB two-inch circular area of redness on R buttock
and immunological deficit of decreased WBC of 3.4 K/UL
DESIRED PATIENT OUTCOME (ONE) Measurable & Patient Centered
Patient’s skin will remain intact, as evidenced by no redness over bony prominences and capillary
refill <6 seconds over areas of redness on
NURSING INTERVENTIONS
RATIONALE FOR EACH NURSING
INTERVENTION
1. Assess general condition of skin and
determine cause.
1. Healthy skin varies from individual to
2. Monitor site of skin impairment at least
individual, but should have good turgor (an
once a day for color changes, redness,
indication of moisture), feel warm and dry to
swelling, warmth, pain or other signs of
the touch, be free of impairment (scratches,
infection. Determine if patient is
bruises, excoriation, rashes), and have quick
experiencing changes in sensation or
capillary refill (less than 6 seconds).
pain. Pay special attention to high-risk
2. Systematic inspection can identify impending
areas such as bony prominences,
problems early.
skinfolds, sacrum, and heels.
3. Areas where skin is stretched tautly over
3. Specifically assess skin over bony
bony prominences are at higher risk for
prominences (sacrum, trochanters,
breakdown because the possibility of
scapulae, elbows, heels, inner and outer
ischemia to skin is high as a result of
malleolus, inner and outer knees, back of
compression of skin capillaries between a
head). Classify stage for pressure ulcers.
hard surface (mattress, chair, or table) and
4. Assess patient's awareness of the
the bone.
sensation of pressure.
4. Normally, individuals shift their weight off
5. Assess patient's ability to move (shift
pressure areas every few minutes; this
weight while sitting, turn over in bed,
occurs more or less automatically, even
move from bed to chair). Ambulate as
during sleep. Patients with decreased
tolerated. Two times per day.
sensation are unaware of unpleasant stimuli
6. Assess patient's nutritional status,
(pressure) and do not shift weight. This
including weight, weight loss, and serum
results in prolonged pressure on skin
albumin levels.
capillaries, and ultimately, skin ischemia.
7. Assess for edema.
5. Immobility is the greatest risk factor in skin
8. Assess for history of radiation therapy.
breakdown.
9. Assess for history or presence of AIDS,
6. An albumin level greater than 2.5 g/100 ml is
or other reasons to be
a grave sign, indicating severe protein
immunocompromised.
depletion. Research has shown that patients
10. Assess for fecal and/or urinary
whose serum albumin is greater than 2.5
incontinence.
g/100 ml are at high risk for skin breakdown,
11. If incontinent, implement an inctonience
all other factors being equal.
management plan to prevent exposure to 7. Skin stretched tautly over edematous tissue
chemicals in urine and stool that can strip
is at risk for impairment.
or erode the skin. Refer to a continence
8. Radiated skin becomes thin and friable, may
care specialist, urologist, or
have less blood supply, and is at higher risk
gastroenterologist for incontinence
for breakdown.
assessment.
9. Early manifestations of HIV-related diseases
12. Assess for environmental moisture
may include skin lesions (e.g., Kaposi's
(wound drainage, high humidity).
sarcoma); additionally, because of their
13. Assess surface that patient spends
immunocompromise, patients with AIDS
majority of time on (mattress for
often have skin breakdown.
bedridden patient, cushion for persons in
10. The urea in urine turns into ammonia within
wheelchairs).
minutes, and is caustic to the skin. Stool may
14. Assess amount of shear (pressure
contain enzymes that cause skin breakdown.
exerted laterally) and friction (rubbing) on
Use of diapers and incontinence pads with
patient's skin.
plastic liners trap moisture and hasten
15. Reassess skin often and whenever the
breakdown.
patient's condition or treatment plan
11. Implementing an incontinence prevention
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results in an increased number of risk
factors.
Monitor client’s skin care practices, noting
type of soap or other cleansing agents
used, temperature of water, and
frequency of skin cleansing.
Individualize plan according to the client’s
skin condition, needs, and preferences.
For clients with limited mobility, use a risk
assessment tool to systematically assess
immobility-related risk factors.
DO not position patient on site of skin
impairment. If consistent with overall
client management goals, turn and
position the client at least every 2 hours.
Transfer the client with care to protect
against adverse effects of external
mechanical forces such as friction,
pressure, and shear.
Evaluate for use of specialty mattress,
beds, or devices as appropriate. Maintain
the HOB at the lowest possible degree of
elevation to reduce shear and friction,
and use lift devises, pillows, foam
wedges, and pressure-reducing devices
in bed.
Implement a written treatment plan for
topical treatment of the site of skin
impairment.
Select a topical treatment that will
maintain a moist wound-healing
environment and that is balanced with the
need to absorb exudate.
Avoid massaging around site of skin
impairment and over bony prominences.
Teach skin to use pillows, foam wedges
and pressure-reducing devices to prevent
pressure injury.
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plan with the use of skin protectant or a
cleanser protectant can significantly
decrease skin breakdown and pressure ulcer
formation.
That may contribute to skin maceration.
Patients who spend the majority of time on
one surface need a pressure reduction or
pressure relief device to distribute pressure
more evenly and lessen the risk for
breakdown.
A common cause of shear is elevating the
head of the patient's bed; the body's weight
is shifted downward onto the patient's
sacrum. Common causes of friction include
the patient rubbing heels or elbows against
bed linen and moving the patient up in bed
without the use of a lift sheet.
The incidence and onset of skin breakdown
is directly related to the number of risk
factors present.
Cleansing should not compromise the skin.
Avoid harsh cleansing agents, hot water,
extreme friction or force, or cleansing too
frequency.
A validated risk assessment tool such as
Braden scale should be used to identify
clients at risk for immobility related skin
breakdown.
DO not position an individual directly on a
pressure ulcer. Continue to turn/reposition
the individual regardless of the support
surface in use. Establish turning frequency
based on the characteristics of the support
surface and the individual’s response.
Having the appropriate mattress and use of
pillows to elevate and separate pressure
spots can reduce pressure ulcers.
A written plan ensures consistency in care
and documentation.
Choose dressings that provide a moist
environment, keep periwound skin dry, and
control exudate and eliminate dead space.
Research suggests that massage may lead
to deep-tissue trauma.
The use of effective pressure-reducing seat
cushions for elderly wheelchair users
significantly prevented sitting-acquired
pressure ulcers.