Potential Nursing Care Plan example from Nursing for Life Organization

1. Nursing Care Plan
"Risk for impaired skin integrity"
Patient
Problem
( Potential )
Nursing diagnosis Risk for impaired skin integrity related to(contributing
factor according to the patient’s condition.
Subjective
Data
 According to the nurse’s observation.
Objective
Data
 According to the patient description.
Objectives
 Patient will demonstrate preventive measures.
 Patient and caregiver will implement strategies to increase safety and
prevent skin impairment.
Nursing
intervention
Assessment
 Assess the overall condition of the skin.
- Rationale: Assessment of the condition of the skin provides baseline data
for possible interventions for the nursing diagnosis Risk for Impaired Skin
Integrity.
 Check on bony prominences such as the sacrum, trochanters, scapulae,
elbows, heels, inner and outer malleolus, inner and outer knees, back of
head).
- Rationale: Specific areas where skin is stretched tautly are at higher risk
for breakdown because the possibility of ischemia to skin is high as a result
of compression of skin capillaries between a hard surface (e.g., mattress,
chair, or table) and the bone. For light pigmented skin, pressure areas
appear to be red. For darker skin tones, these areas appear to be red, blue,
or purple hue spots.
 Evaluate the patient’s awareness of the sensation of pressure.
- Rationale: Usually, individuals change position off pressure areas every
few minutes; these occur automatically even during sleep. Patients who
are unaware of sensation tend to do nothing thus results in prolonged
pressure on skin capillaries and eventually in skin ischemia.

2.  Evaluate the patient’s strength to move (e.g., shift weight while sitting,
turn over in bed, move from bed to chair).
- Rationale: The greatest risk factor in skin breakdown is immobility.
 Assess patient’s nutritional status, including weight, weight loss, and
serum albumin levels.
- Rationale: An albumin level less than 2.5 g/dL is a grave sign, indicating
severe protein depletion and at high-risk of skin breakdown.
 Assess for fecal/urinary incontinence.
- Rationale: Stool may contain enzymes that cause skin breakdown. The
urea in urine turns into ammonia within minutes and is caustic to the skin.
Use of diapers and incontinence pads hastens skin breakdown.
 Assess for a history or presence of AIDS or other immunological problems.
- Rationale: Skin lesions or Kaposi’s sarcoma is an early manifestation of
diseases related to HIV.
 Assess for a history of radiation therapy.
- Rationale: Radiated skin becomes thin and friable, may have less blood
supply, and is at higher risk for breakdown.
 Assess for edema.
- Rationale: Skin tightened tautly over edematous tissue is at risk for
impairment.
 Assess the amount of shear (pressure exerted laterally) and friction
(rubbing) on the patient’s skin.
- Rationale: A typical cause of shear is elevating the head of the patient’s
bed: the body’s weight is displaced downward onto the patient’s sacrum.
Typical causes of friction include the patient rubbing heels or elbows
against bed linen, and moving the patient up in bed without the use of a
lift sheet.
 Assess the surface that the patient consumes most of his or her time on
(e.g., mattress for bedridden patient, cushion for people in wheelchairs).
- Rationale: Patients who spend the majority of time on one surface require
a pressure reduction or pressure relief device to distribute pressure more
evenly and reduce the risk for breakdown.
 Assess for environmental moisture (e.g., wound drainage, high humidity).
- Rationale: Moisture may contribute to skin maceration.

3. Interventions
 Discourage the patient or caregiver from elevating the head of bed
repeatedly. Encourage the use of lifting devices like trapeze or bed linen
to move the patient in bed.
- Rationale: Common causes of impaired skin integrity is friction which
involves rubbing heels or elbows toward bed linen and moving the patient
up in bed without the use of a lift sheet. A common cause of shear is
elevating the head of the patient’s bed: the body’s weight is shifted
downward onto the patient’s sacrum.
 Encourage the patient to change position every 15 minutes and change
chair-bound positions every hour.
- Rationale: During sitting, the pressure over the sacrum may exceed 100
mm Hg. The pressure needed to close capillaries is around 32 mm Hg; any
pressure above 32 mm Hg leads to ischemia.
 Encourage the implementation of pressure-relieving devices
commensurate with degree of risk for skin impairment:
 For low-risk patients: good-quality (dense, at least 5 inches thick) foam
mattress overlay
- Rationale: Eggcrate-type mattresses less than 4 to 5 inches thick do not
relieve pressure. Because they are made of foam, moisture can be
trapped. A false sense of security with the use of these mattresses can
delay initiation of devices useful in relieving pressure.
 For moderate-risk patients: water mattress, static or dynamic air mattress
- Rationale: Dynamic devices electronically alternate inflation and
deflation of the device. Static devices consist of gel, foam, water, or air
that remains in a constant state of inflation. In the home, a waterbed is a
good alternative.
 For high-risk patients or those with existing stage III or IV pressure ulcers
(or with stage II pressure ulcers and multiple risk factors): low-air-loss beds
(Mediscus, Flexicare, KinAir) or air-fluidized therapy (Clinitron, Skytron)
- Rationale: Low-air-loss beds allow elevated head of bed and patient
transfer. These should be used when pulmonary concerns necessitate
elevating the head of bed or when getting the patient up is feasible. Air-
fluidized therapy supports the patient’s weight at well below capillary
closing pressure but restricts getting the patient out of bed easily.
 Encourage the implementation of a turning schedule, restricting time in
one position to 2 hours or less, if the patient is restricted to bed.
- Rationale: Turning every 2 hours is the key to prevent breakdown. Head
of bed should be kept at 30 degrees or less to avoid sliding down on bed.

4.  Use pillows or foam wedges to keep bony prominences from direct
contact with each other. Keep pillows under the heels to raise off bed.
- Rationale: These measures reduce shearing forces on the skin.
 Encourage ambulation if the patient is able.
- Rationale: Ambulation reduces pressure on the skin from immobility thus
lessening the factors that may result in impaired skin integrity.
 Encourage adequate nutrition and hydration:
 2000 to 3000 kcal/day (more if increased metabolic demands)
 Fluid intake of 2000 mL/day unless medically restricted.
- Rationale: Sufficient hydration and nutrition help maintain skin turgor,
moisture, and suppleness, which provide resilience to damage caused by
pressure. Patients with limited cardiovascular reserve may not be able to
tolerate much fluid.
 Clean, dry, and moisturize skin, particularly bony prominences, twice daily
or as indicated by incontinence or sweating. Avoid hot water. If powder is
desirable, use medical grade cornstarch; avoid talc.
- Rationale: Smooth, supple skin is more resistant to injury. These
measures prevent evaporation away from skin. Avoid talc which may
cause lung injury.
Health
Teaching
 Educate patient and caregiver about the causes of pressure.
- Rationale: This information can assist the patient or caregiver in finding
methods to prevent skin breakdown.
 Reinforce the importance of turning, mobility, and ambulation.
- Rationale: These will enhance their sense of efficacy and can improve
compliance with the prescribed interventions.
 Educate patients and caregivers about proper skin care.
- Rationale: Educating patients and caregivers methods to maintain skin
integrity enhances their sense of self-efficacy and prevents skin
breakdown.
Evaluation
Achieved ( ) Partially achieved ( ) Not achieved ( )

5. Evidence by:
Important Note
"We just recommend examples of nursing care plans. There are many references and
interventions may change according to patient condition. You should consider this, search,
and see more than one reference to reach the best quality for writing the care plan"