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risk for impaired skin integrity



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Mar 03, 2007 05:01 PM

risk for impaired skin integrity


We are starting clincial Monday (nsg101) and have to go in with a generic risk for impaired skin integrity.

the outcomes I can think of are 1. maintain clean and intact skin 2. vital signs WNL (don't know if I really need that one on this) 3. client will id risk factors 4. client will demonstrate techniques to prevent skin breakdown 5. client will verbalize understanding of treatment 6. client will report any altered sensation or pain

I've only got 12 interventions and I'm sure there should be more.

I just feel like I'm missing something really simple on this. We'll be going to a LTC. Any advice would be appreciated.


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19 Comments
No. 1
from burn out
Old Mar 03, 2007, 05:15 PM
Updated Mar 03, 2007 at 05:20 PM by burn out

Default Re: risk for impaired skin integrity
some areas to consider when assessing for impaired skin interity are

1. nutrition..if the patient is malnourished nothing you can do will prevent
or heal impaired skin. Even those that can eat will need increased protein to promote wound healing.

2. elimination..if the patient is incontinent either bowel or bladder will contribute to intact skin breaking down and infecting as well as preventing impaired skin from healing.

3.Activity..is the patient bed ridden and can not turn themselves or can they reposition themselves?

4. Education if the patient is coherent enough to understand,,,most nursing home patients have some degreee of dementia, in home health sitting however education of care giver is very important.

5. Ongoing assessment of treatment to determine if wound tissue is healing properly and if treatment is effective.

6.other disease process that may interfere with wound healing i.i. diabetes, or peripheral vascular disease
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No. 2
from Achoo!
Old Mar 03, 2007, 05:15 PM

Default Re: risk for impaired skin integrity
What interventions do you have?
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No. 3
Old Mar 03, 2007, 05:21 PM

Default Re: risk for impaired skin integrity
my interventions are

repostition client q2h
maintain nutrition and hydration intake 2000 ml/day
use lift sheets to move client in bed
teach client causes of pressure ulcers
encourage ambulation if able
keep bedclothes dry and free of wrinkles
keep skin dry and clean
monitor sites of risk qshift and prn
bathe client every other day
if incontinent, check q2h and change/clean prn
use pillows or pressure reducing devices
avoid massaging red areas or bony prominence
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No. 4
from Achoo!
Old Mar 03, 2007, 06:23 PM

Default Re: risk for impaired skin integrity
Skin assessment q shift
vitals q shift
Teach pt s/s of infection ( be specific)
Monitor labs q shift ( WBC for sure)
If pt is not ambulatory, leg excercises regularly to increase circulation
Remove invasive devices as soon as possible ( IV's or catheters)
Staff will perform hand hygeine before each encounter
Use standard precautions when in contact with body fluids
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No. 5
from Daytonite
Old Mar 03, 2007, 08:18 PM

Hi, firewife1997!

Here are two websites with information on outcomes and nursing interventions for Impaired Skin Integrity:

http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=48
http://www1.us.elsevierhealth.com/Evolve/Ackley/NDH7e/Constructor/careplan_063.php

Welcome to allnurses!
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No. 6
from risperdal
Old Apr 27, 2008, 10:28 AM

Default Re: risk for impaired skin integrity
just a question here, exactly what does NANDA mean with "Altered epidermis and/or dermis" as the definition for Impaired Skin Integrity?

does dry skin qualify as Impaired Skin Integrity, or does it fall under Risk for Impaired Skin Integrity?

thanks
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No. 7
from Daytonite
Old Apr 27, 2008, 12:40 PM

They mean that there has been a disruption, or break in the skin, from its normal anatomical unimpairedness that extends through the two top layers of the skin, the dermis and epidermis.

I would use Risk for Injury (skin breaks) for dry skin because that is what a skin breakdown of dry skin would be, a traumatic injury to the tissues and you want to prevent the injury from happening.
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No. 8
from ktwlpn
Old Apr 27, 2008, 01:41 PM

Default Re: risk for impaired skin integrity
Originally Posted by firewife1997 View Post
I just feel like I'm missing something really simple on this. We'll be going to a LTC. Any advice would be appreciated.
Don't forget staff education-very important in LTC.
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No. 9
from risperdal
Old Apr 30, 2008, 12:03 PM

Default Re: risk for impaired skin integrity
Originally Posted by Daytonite View Post
They mean that there has been a disruption, or break in the skin, from its normal anatomical unimpairedness that extends through the two top layers of the skin, the dermis and epidermis.

I would use Risk for Injury (skin breaks) for dry skin because that is what a skin breakdown of dry skin would be, a traumatic injury to the tissues and you want to prevent the injury from happening.
i knew i was right...got into an argument with my review lecturer on this last week
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