Nurse's Pocket Guide

Desired Outcomes/Evaluation
Criteria—Client Will:
• Identify individual risk factors.
• Verbalize understanding of treatment/therapy regimen.
• Demonstrate behaviors/techniques to prevent skin breakdown.
Actions/Interventions
NURSING PRIORITY NO.1.To assess causative/contributing factors:
• Assess skin routinely, noting moisture, color, and elasticity.
Review with client/SO history of past skin problems (e.g.,
allergic reactions, rashes, easy bruising/skin tears) that may
indicate particular vulnerability.
• Note presence of conditions/situations that may impair skin
integrity (e.g., age-related changes in skin and muscle mass,
general debilitation, impaired mobility, poor nutritional status,
presence of chronic conditions/immunosuppression,
incontinence, problems of self-care, side/adverse effects of
medication or therapy).
• Assess for diminished circulation in lower extremities. Calculate
ankle-brachial index (ABI), as appropriate (diabetic clients or
others with impaired circulation to lower extremities). Result
less than 0.9 indicates need for more aggressive preventive
interventions (e.g., stricter blood glucose and weight control).
• Review pertinent laboratory results (e.g., studies such as
Hb/Hct, blood glucose, infectious agents [viral/bacterial/fungal],
albumin/protein). Note: Albumin less than 3.5 correlates
to decreased wound healing/increased pressure ulcers.
NURSING PRIORITY NO.2.To maintain skin integrity at optimal level:
• Handle client gently (particularly infant, young child, elderly).
Epidermis of infants and very young children is thin
and lacks subcutaneous depth that will develop with age.
Skin of the older client is also thin, less elastic, and prone to
injury, such as bruising and skin tears.
• Inspect skin surfaces/pressure points routinely, especially in
mobility-impaired client.
• Observe for reddened/blanched areas or skin rashes, and
institute treatment immediately. Reduces likelihood of progression
to skin breakdown.
• Maintain meticulous skin hygiene, using mild nondetergent
soap, drying gently and thoroughly, and lubricating with
lotion or emollient, as indicated.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 625
risk for impaired SKIN INTEGRITY