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