Impaired Skin Integrity
Impaired Skin Integrity
(_)Actual (_) Potential
| (_)
Burns of_______________________ (_) Decreased sensation (_) Immobility (_) Malnutrition (_) Pressure ulcer (_) Puritus (_) Stoma problems (_) Other:_____________________________ ____________________________________ ____________________________________ |
| 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:
(_) 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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