Nursing Interventions for Impaired Skin Integrity

 

Perform:

 	
Ongoing skin inspection, noting skeletal prominences, areas of altered circulation, pigmentation, obesity, and emaciation
 	
Checks for edema
 	
Removal of antiembolism stockings for 30-60 minutes at least twice a day

Provide:

 	
Frequent skin care, minimize contact with moisture/excretions
 	
Gentle massage around the affected areas -red and blanched

 	
Avoid the affected area directly, as it may cause tissue injury


 	
Assistance with active and passive range of motion exercises (ROM)
 	
Alternating pressure/egg-crate mattresses, pillows, sheepskin elbow/ heel protectors such as gel or foam cushions

 	
Reduce pressure on the skin, improve circulation
 	
Assist patient with turning every two hours


 	
Bed cradle or footboard to relieve pressure from bed linens
 	
Tools, such as foam blocks or pillows to help elevate extremities

Avoid:

 	
Intramuscular route for medication-impeded drug absorption
 	
Tight shoes or slippers- edema may cause shoes to. Fit poorly, increased risk of breakdown due to pressure on skin on feet
 	
Excessive dryness or moisture as they can damage the skin and hasten a breakdown

Patient Education:

 	
Pressure management to prevent ulceration
 	
Check for a fit of shoes and slippers, and change as needed
 	
Encourage smoking cessation
 	
Educate about tips to conserve energy

Documentation and Evaluation
Documentation is vital to safe patient care. The nurse is responsible for photographing and precise terminology to accurately describe a wound. Accurate documentation includes location, type of wound, measurement, color, texture and drainage, and any interventions initiated.

It’s also important to document the patient’s response to the wound and wound care. The evaluation of nursing interventions and patient education are part of the nursing process, which will help the patient to achieve the best outcome possible.

Impaired Skin Integrity NCLEX Questions
Based on the patient’s case, what factors predict impaired skin integrity?

Answer: prolonged bed rest, pain, warmness, obesity, impaired renal function

What are signs and symptoms of infection?

 	
Symptoms of sepsis
 	
Wound purulence
 	
Altered mental status
 	
Increased white blood cells
 	
All of the above

What medications should be avoided in patients with impaired skin integrity?

 	
Transdermal patches
 	
Topical agents
 	
Intramuscular route
 	
All of the above

References:
Doenges, Marilynn E., et al. Nursing Care Plans: Guidelines for Individualizing Client Care. F.A. Davis, 2006.