Impaired Skin Integrity

Published on Saturday March 10th , 2007

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

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