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Nursing Diagnosis: Risk for Impaired Skin Integrity
Pressure Sores; Pressure Ulcers; Bed Sores; Decubitus Care

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels Risk Control Risk Detection Tissue Integrity: Skin and Mucous Membranes

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels Pressure Ulcer Prevention Skin Surveillance NANDA Definition: At risk for skin being adversely altered Immobility, which leads to pressure, shear, and friction, is the factor most likely to put an individual at risk for altered skin integrity. Advanced age; the normal loss of elasticity; inadequate nutrition; environmental moisture, especially from incontinence; and vascular insufficiency potentiate the effects of pressure and hasten the development of skin breakdown. Groups of persons with the highest risk for altered skin integrity are the spinal cord injured, those who are confined to bed or wheelchair for prolonged periods of time, those with edema, and those who have altered sensation that triggers the normal protective weight shifting. Pressure relief and pressure reduction devices for the prevention of skin breakdown include a wide range of surfaces, specialty beds and mattresses, and other devices. Preventive measures are usually not reimbursable, even though costs related to treatment once breakdown occurs are greater. Risk Factors: Extremes of age Immobility Poor nutrition Mechanical forces (e.g., pressure, shear, friction) Pronounced bony prominences Poor circulation Altered sensation Incontinence Edema Environmental moisture History of radiation Hyperthermia or hypothermia Acquired immunodeficiency syndrome (AIDS)

because of their immunocompromise. or table) and the bone. excoriation. Patients who spend the majority of time on one surface need a pressure reduction or pressure relief device to distribute pressure more evenly and lessen the risk for breakdown. Assess for fecal and/or urinary incontinence. Elderly patients’ skin is normally less elastic and has less moisture. all other factors being equal. Assess patient’s ability to move (e. Patients with decreased sensation are unaware of unpleasant stimuli (pressure) and do not shift weight. Common causes of friction include the patient rubbing heels or . Skin stretched tautly over edematous tissue is at risk for impairment. shift weight while sitting.5 g/dl are at high risk for skin breakdown.g. cushion for persons in wheelchairs). scapulae.. Assess for edema. Assess patient’s awareness of the sensation of pressure. indicating severe protein depletion. Research has shown that patients whose serum albumin is less than 2. inner and outer malleolus. Assess for environmental moisture (e. Healthy skin varies from individual to individual. Radiated skin becomes thin and friable..g. An albumin level less than 2. and ultimately. Areas where skin is stretched tautly over bony prominences 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. mattress. making for higher risk of skin impairment. and is at higher risk for breakdown.. Use of diapers and incontinence pads with plastic liners traps moisture and hastens breakdown.. Stool may contain enzymes that cause skin breakdown. turn over in bed.. Moisture may contribute to skin maceration. even during sleep. Assess amount of shear (pressure exerted laterally) and friction (rubbing) on patient’s skin. feel warm and dry to the touch. Kaposi’s sarcoma). 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. chair. mattress for bedridden patient. Normally. may have less blood supply.g. as evidenced by no redness over bony prominences and capillary refill less than 6 seconds over areas of redness. Assess for history or presence of AIDS. Immobility is the greatest risk factor in skin breakdown. Assess patient’s nutritional status. bruises. wound drainage.g.. heels. back of head). rashes). Assess for history of radiation therapy. Assess surface that patient spends majority of time on (e. elbows. weight loss. additionally. Early manifestations of HIV-related diseases may include skin lesions (e. patients with AIDS often have skin breakdown. The urea in urine turns into ammonia within minutes and is caustic to the skin. skin ischemia. Ongoing Assessment Determine age. move from bed to chair).g.5 g/dl is a grave sign.g. be free of impairment (scratches. but should have good turgor (an indication of moisture).Expected Outcomes Patient’s skin remains intact. Specifically assess skin over bony prominences (e. trochanters. high humidity). This results in prolonged pressure on skin capillaries. Assess general condition of skin. including weight. sacrum. individuals shift their weight off pressure areas every few minutes. and have quick capillary refill (<6 seconds). and serum albumin levels. inner and outer knees. this occurs more or less automatically.

restricting time in one position to 2 hours or less and customizing the schedule to patient’s routine and caregiver’s needs. Massaging reddened area may damage skin further. Kinair) or air-fluidized therapy (Clinitron. Encourage use of lift sheets to move patient in bed and discourage patient or caregiver from elevating HOB repeatedly. "Air-fluidized" therapy supports patient’s weight at well below capillary closing pressure but restricts getting patient out of bed easily. especially over bony prominences. The pressure necessary to close skin capillaries is around 32 mm Hg. Encourage patient and/or caregiver to maintain functional body alignment. or applying a hydrocolloid (Duoderm. Leave blisters intact by wrapping in gauze. Reassess skin often and whenever the patient’s condition or treatment plan results in an increased number of risk factors. dry. Blisters are sterile natural dressings. For moderate risk patients: water mattress. Fluid intake of 2000 ml/day unless medically restricted. Tegaderm). and moving the patient up in bed without the use of a lift sheet. Encourage ambulation if patient is able. Pressure over sacrum may exceed 100 mm Hg pressure during sitting. Leaving them intact . Clean. Hydrated skin is less prone to breakdown. A false sense of security with the use of these mattresses can delay initiation of devices useful in relieving pressure. any pressure greater than 32 mm Hg results in skin ischemia. Increase tissue perfusion by massaging around affected area. moisture can be trapped. These should be used when pulmonary concerns necessitate elevating HOB or when getting patient up is feasible. The incidence and onset of skin breakdown is directly related to the number of risk factors present. A schedule that does not interfere with the patient’s and caregivers’ activities is most likely to be followed.elbows against bed linen. Patients with limited cardiovascular reserve may not be able to tolerate this much fluid. and moisturize skin. Sween-Appeal) or a vapor-permeable membrane dressing (Op-Site. because they are made of foam. static or dynamic air mattress In the home. Skytron) Low-air-loss beds are constructed to allow elevated head of bed (HOB) and patient transfer. Therapeutic Interventions If patient is restricted to bed: Encourage implementation and posting of a turning schedule. If powder is desirable. a waterbed is a good alternative. Encourage implementation of pressure-relieving devices commensurate with degree of risk for skin impairment: For low-risk patients: good-quality (dense. Flexicare. use medicalgrade cornstarch. For high-risk patients or those with existing stage III or IV pressure sores (or with stage II pressure sores and multiple risk factors): low-air-loss beds (Mediscus. Limit chair sitting to 2 hours at any one time. avoid talc. Encourage adequate nutrition and hydration: 2000 to 3000 kcal/day (more if increased metabolic demands). at least 5 inches thick) foam mattress overlay Egg crate mattresses less than 4 to 5 inches thick do not relieve pressure. twice daily or as indicated by incontinence or sweating. These measures reduce shearing forces on the skin.

Teach patient or caregiver the proper use and maintenance of pressurerelieving devices to be used at home.maintains the skin’s natural function as barrier to pathogens while the impaired area below the blister heals. please contact: Webmaster . or ambulation in prevention of pressure ulcers. All rights reserved. Education/Continuity of Care Consult dietitian as appropriate. Include Rationales? Create the Care Plan Copyright © 2010 Mosby . turning. an imprint of Elsevier Inc. especially over bony prominences Incontinence Poor nutrition Shearing or friction against skin Reinforce the importance of mobility. Teach patient and caregiver the cause(s) of pressure ulcer development: Pressure on skin. For problems or suggestions regarding this service.

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