Describe the pressure ulcer staging system.Discuss the risk factors that contribute to pressure ulcer formation.Ulrich & Canale’s Nursing Care Planning Guides: Prioritization, Delegation, and Critical Reasoning. Nursing Care Plans: Guidelines for Individualizing Client Care. Using bed cradle or footboard to relieve pressure from bed linens.Massaging areas of impaired circulation.Ensuring proper nutrition and hydration.Alternating pressure/egg-crate mattress, pillows, sheepskin elbow/ heel.List at least 3 tips for preventing impaired skin integrity antiembolism stockings should never be removed.

How often and how long should antiembolism stockings be removed on a daily basis? What medications should be avoided in clients with impaired skin integrity? Questions: Based on the client case, what factors are predictive of impaired skin integrity?Īnswer: prolonged bed rest, pain, warmness, obesity, impaired renal function What are signs and symptoms of infection? Client’s BMI is 37.5 and he also suffers from stage 3 kidney disease. Client mentions he is experiencing warmness and pain in the lower back.

Control edema interstitial edema and impaired circulation slow down drug absorption and predispose to tissue breakdown/ development of infectionĬlient has been admitted in the NICU for 13 days after a stroke accident.

Check for fit of shoes, slippers and change as needed.

Pressure management to prevent ulceration.

Client understanding and demonstration of behaviors and techniques to prevent skin breakdowns.

Post intervention evaluation/monitoring Monitor

Demonstrates behaviors/techniques to prevent skin breakdowns.

Maintain skin integrity/ no skin breakdowns.

Frequent positions changes in bed/chair-reduces pressure on tissue, improving circulation and reducing the time the area is deprived of blood flow.

Antidysrhythmic agents, Anticholinergic agents, pain medications if needed.

Excessive dryness or moisture as they can damage skin and hasten breakdown.

Fit poorly, increased risk of breakdown due pressure on skin on feet Tight shoes or slippers- edema may cause shoes to.Intramuscular route for medication-impeded drug absorption.Tools, such as foam blocks or pillows to help elevate extremities.Bed cradle or footboard to relieve pressure from bed linens.Assist client with turning every 2 hours.Reduce pressure to skin, improve circulation.Alternating pressure/egg-crate mattress, pillows,sheepskin elbow/ heel protectors such as gel or foam cushions.Assistance with active and passive range of motion exercises (ROM).Avoid the affected area directly as it may cause tissue injury.Provide gentle massage around the affected areas -red and blanched.Frequent skin care, minimize contact with moisture/excretions.Notify appropriate health care providers if needed-wound care specialist, physician.Remove antiembolism stockings for 30-60 minutes at least twice a day.Skin inspection, noting skeletal prominences, areas of altered circulation, pigmentation, obesity and emaciation.Provide information about disease/prognosis, therapy needs, and prevention of recurrences.Prevent complications-risk of infection.Proper positioning of clients, including foam blocks, pillows, bed cradles.Improve myocardial contractility/systemic perfusion.Presence of signs and symptoms establishes an actual diagnosis Risk for impaired skin integrity care plan Inspect the skin (especially bony prominences, dependent areas, and affected extremity for pallor, redness and breakdown Rationale:

Impaired Skin Integrity Nursing diagnosis Assessment Breakdown of skin covering bony prominences.altered sensation at site if tissue impairmentĬollect client history, including risk factors and symptoms (objective and subjective data) Cardiac Function:.Implementing the risk for impaired skin integrity care plan can help prevent further complications, especially discomfort and risk of infections. Impaired skin integrity nursing diagnosis and early recognition allows for prompt intervention. Physical immobility, prolonged bed rest, alterations in nutritional status often result in impaired peripheral circulation, compromising the tissue nutrient delivery and skin integrity.