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Impaired Skin Integrity

Impaired Skin Integrity

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Burns of_______________________
(_) Decreased sensation
(_) Immobility
(_) Malnutrition
(_) Pressure ulcer
(_) Puritus
(_) Stoma problems
(_) Other:_____________________________
____________________________________
____________________________________

 

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Disruption of epidermal and dermal tissue.
Minor:
(
May be present)
(_) Denuded skin.
(_) Erythema.
(_)Lesions.

Other:

 

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
  The patient will:

(_)Maintain or develop clean and intact skin.

(_) Other:

  (_) Inspect and chart skin integrity q_____hrs.

(_) Do wound care/dressing change as ordered. Describe:__________
________________________
________________________
________________________
________________________
________________________

(_) Provide measures to decrease pressure/irritation to skin:

  • fleece pad
  • egg crate mattress
  • keep skin clean and dry
  • other:

(_) Turn and reposition q____hrs.

(_) Up in chair for ___ minutes q____.

(_) Gently massage bony prominences and pressure points with lotion q____.

(_) Maintain adequate nutrition and hydration.

(_) Change incontinent pad ASAP after voiding or defecation.

(_) Expose skin to air if indicated.

(_) Initiate health teaching and referrals as indicated. List:___________
________________________
________________________

(_) Keep nails short.

(_) Mittens to decrease skin breakdown from scratching. (These are considered a restraint in some facilities. Get an order first.)

(_) Change ostomy appliance prn when leaking.

(_) Other:________________
________________________
________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature