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

What interventions do you have?

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

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!

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

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.

Don't forget staff education-very important in LTC.

i knew i was right...got into an argument with my review lecturer on this last week