risk for impaired skin integrity

  1. 0
    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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  4. 1
    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
    Last edit by burn out on Mar 3, '07
    billythekid likes this.
  5. 0
    What interventions do you have?
  6. 0
    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
  7. 0
    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
  8. 1
    hi, firewife1997!

    here are two websites with information on outcomes and nursing interventions for impaired skin integrity:

    http://www1.us.elsevierhealth.com/me...ex.cfm?plan=48
    [color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_063.php

    welcome to allnurses!
    billythekid likes this.
  9. 0
    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
  10. 1
    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.
    risperdal likes this.
  11. 0
    Quote from firewife1997
    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.
  12. 0
    Quote from Daytonite
    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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