Skin Integrity

Skin Integrity: Skin Breakdown on Nine General

Immobility + Bony Prominences

—Common areas for skin ulcers are the head, shoulder blades, elbows, sacrum, and heels
—Pressure relief on these areas is crucial

Impaired Skin Integrity

—Major risk factors are decreased level of consciousness, limited mobility, impaired senses, and incontinence (Jaul, 2010)
—Edema, dehydration, poor nutrition, medications, immunosuppression, and decreased oxygenation also contribute (Jaul, 2010)

—Pressure management

Nonrestrictive clothing, monitor mobility and activity, facilitate small shifts of body weight, turn the patient every two hours, refrain from applying pressure, use toe pleats and heel protectors, monitor nutritional status (Bulechek et al., 2008, p 585)

Interventions

—Document skin status on admission
—Clean, dry linens
—Document weight
—Moisture dry, unbroken skin
—Avoid donut devices
—Use protective devices
—Keep skin dry
—Monitor for sources of friction or pressure
—Follow accepted recommendations for repositioning
—Use appropriate devices to avoid improper contact (Bulecheck et al., 2008, p. 587)

Desired Outcome: Tissue Integrity
—Skin structure is intact and function is normal (Moorhead, Johnson, Maas, & Swanson, 2008, p. 699)
—Rating Scale:
—1 Severely Compromised
—2 Substantially Compromised
—3 Moderately Compromised
—4 Mildly Compromised
—5 Not Compromised (Moorhead et al., 2008, p. 699)

References

—Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (Eds.). (2008). Nursing interventions classification (NIC) (5th ed.). St. Louis, MO: Mosby Elsevier.
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Jaul, E. (2010). Assessment and management of pressure ulcers in the elderly: current strategies. Drugs & Aging, 27(4), 311-325.
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Johnson, M., Bulechek, G., Butcher, H., Dochterman, J. M., Maas, M., Moorhead, S., & Swanson, E. (Eds.). (2006). NANDA, NOC, and NIC Linkages (2nd ed.). St. Louis, MO: Mosby Elsevier.
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Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (Eds.). (2008). Nursing outcomes classification (NOC) (4th ed.). St. Louis, MO: Mosby Elsevier.

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