StudyLoop

Nursing Interventions for Impaired Skin Integrity

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Perform:

  • Ongoing skin inspection, noting skeletal prominences, areas of altered circulation, pigmentation, obesity, and emaciation
  • Checks for edema
  • Removal of antiembolism stockings for 30-60 minutes at least twice a day

Provide:

  • Frequent skin care, minimize contact with moisture/excretions
  • Gentle massage around the affected areas -red and blanched
    • Avoid the affected area directly, as it may cause tissue injury
  • Assistance with active and passive range of motion exercises (ROM)
  • Alternating pressure/egg-crate mattresses, pillows, sheepskin elbow/ heel protectors such as gel or foam cushions
    • Reduce pressure on the skin, improve circulation
    • Assist patient with turning every two hours
  • Bed cradle or footboard to relieve pressure from bed linens
  • Tools, such as foam blocks or pillows to help elevate extremities

Avoid:

  • Intramuscular route for medication-impeded drug absorption
  • Tight shoes or slippers- edema may cause shoes to. Fit poorly, increased risk of breakdown due to pressure on skin on feet
  • Excessive dryness or moisture as they can damage the skin and hasten a breakdown

Patient Education:

  • Pressure management to prevent ulceration
  • Check for a fit of shoes and slippers, and change as needed
  • Encourage smoking cessation
  • Educate about tips to conserve energy

Documentation and Evaluation

Documentation is vital to safe patient care. The nurse is responsible for photographing and precise terminology to accurately describe a wound. Accurate documentation includes location, type of wound, measurement, color, texture and drainage, and any interventions initiated.

It’s also important to document the patient’s response to the wound and wound care. The evaluation of nursing interventions and patient education are part of the nursing process, which will help the patient to achieve the best outcome possible.

Medical nurse wearing blue sterile gloves holding old disabled woman's hands
Medical nurse wearing blue sterile gloves holding old disabled woman’s hands

Impaired Skin Integrity NCLEX Questions

Based on the patient’s case, what factors predict impaired skin integrity?

Answer: prolonged bed rest, pain, warmness, obesity, impaired renal function

What are signs and symptoms of infection?

  1. Symptoms of sepsis
  2. Wound purulence
  3. Altered mental status
  4. Increased white blood cells
  5. All of the above

What medications should be avoided in patients with impaired skin integrity?

  1. Transdermal patches
  2. Topical agents
  3. Intramuscular route
  4. All of the above

References:

Doenges, Marilynn E., et al. Nursing Care Plans: Guidelines for Individualizing Client Care. F.A. Davis, 2006.