risk for impaired skin integrity

burn out · Mar 3, 2007

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

Achoo!, LPN · Mar 3, 2007

What interventions do you have?

firewife1997 · Mar 3, 2007

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

Achoo!, LPN · Mar 4, 2007

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

Daytonite, BSN, RN · Mar 4, 2007

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

[color=#3366ff]http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/careplan_063.php

welcome to allnurses! :welcome:

risperdal · Apr 27, 2008

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 :)

Daytonite, BSN, RN · Apr 27, 2008

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.

ktwlpn, LPN · Apr 27, 2008

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.

risperdal · Apr 30, 2008

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

Daytonite, BSN, RN · May 1, 2008

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

to help prove your point, it helps to show the written nanda taxonomy on this. the proof is in the nanda definitions of these two diagnoses. you could use a care plan book or nursing diagnosis reference book that has the nanda information, that will work. or, you can print out these pages that have the nanda information right below the diagnosis titles:

GAstudentNurse · Mar 4, 2009

Hello everyone. I'm new here. I hope to graduate in the summer, but have gone from making all A's in clinicals/school last semester to C's this semester. Any help would be appreciated!

I have a two careplans due. Diagnoses: Diabetes, COPD, PVD. Am thinking of Fluid Volume Excess AEB 1+ pitting edema, SOB at rest and exertion, and altered labs (Hbg, Hct). I'm struggling with goals! They must be, "realistic" goals (2 days). The patient also has kidney disease. For second careplan, I'm thinking of, "Risk for Impaired Skin Integrity". Other abnormal labs: Albumin (which I know will support that NANDA, and not sure if the other abnormal labs would but they include, Glucose, BUN/Creatine, CBC-RBC, Hgb, Hct, RDW, Lymphs). Any advice would be greatly appreciated. My patient is elderly and is a resident in a nursing home and was admitted due to complications with Diabetes. I'm not sure if I should choose Impaired Physical Mobility for second careplan or not. She isn't really mobile (just to the bedside commode) at times, adult diapers otherwise. I'm just having trouble tonight. Just a little steering would be greatly appreciated!

I have been visiting this site for months now..........enjoy reading and learning! Thanks in advance for those that may take the time to respond!

Last thought........can you use a medication as AEB......such as Lasix for FVE? Or, is that an intervention?