Nurse's Pocket Guide

isk for impaired SKIN INTEGRITY
• Massage bony prominences and use proper positioning, turning,
lifting, and transferring techniques when moving client
to prevent friction or shear injury.
• Change position in bed/chair on a regular schedule. Encourage
client participation in early ambulation, active and assistive
range-of-motion exercises.
• Provide adequate clothing/covers; protect from drafts to prevent
vasoconstriction.
• Keep bedclothes dry and wrinkle-free, use nonirritating linens.
• Provide protection by use of pads, pillows, foam mattress,
water bed, etc., to increase circulation and limit/eliminate
excessive tissue pressure.
• Use paper tape or a nonadherent dressing on frail skin and
remove it gently. Or use stockinette, gauze wrap, or any other similar
type of wrap instead of tape to secure dressings and drains.
• Provide for safety measures during ambulation and other therapies
that might cause dermal injury (e.g., use of properly fitting
hose/footwear, safe use of heating pads/lamps, restraints).
• Provide preventative skin care to incontinent client: Change
continence pads/diapers frequently; cleanse perineal skin
daily and after each incontinence episode apply skin protectant
ointment to minimize contact with irritants (urine,
stool, excessive moisture)
NURSING PRIORITY NO. 3. To promote wellness (Teaching/
Discharge Considerations):
• Provide information to client/SO(s) about the importance of
regular observation and effective skin care in preventing
problems.
• Emphasize importance of adequate nutritional/fluid intake to
maintain general good health and skin turgor.
• Encourage continuation of regular exercise program (active/
assistive) to enhance circulation.
• Recommend elevation of lower extremities when sitting to
enhance venous return and reduce edema formation.
• Encourage restriction/abstinence from tobacco, which can
cause vasoconstriction.
• Suggest use of ice, colloidal bath, lotions to decrease irritable
itching.
• Recommend keeping nails short or wearing gloves to reduce
risk of dermal injury when severe itching is present.
• Discuss importance of avoiding exposure to sunlight in specific
conditions (e.g., systemic lupus, tetracycline/psychotropic
drug use, radiation therapy) as well as potential for development
of skin cancer.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
626 Cultural Collaborative Community/Home Care