What Is Optimal Skin Integrity

Impaired Pare Integrity Nursing Care Plans Diagnosis and Interventions

Impaired Skin Integrity NCLEX Review and Nursing Intendance Plans

The skin is a waterproof, flexible organ that covers the human body. Its three main purposes are: (i) to protect the trunk, (2) to regulate temperature, and (3) to provide sensation.

The peel is the largest organ of the body and is equanimous of three layers – the epidermis (outer layer), dermis (heart layer), and hypodermis (innermost layer).

Protecting the integrity of the skin is an important part of holistic nursing care. The regular assessment of skin wellness is part of the daily evaluation healthcare staff make to ensure holistic care.

Therefore, knowing proper skin care and learning nigh the possible causes and risk factors that predispose patients to have a breech in their pare integrity are essential in nursing care.

The post-obit are the gamble factors that can predispose individuals to pare damage:

The utilise of chemical irritants that may be present in regular household items such as soaps and pilus dye
Having skin conditions such equally dermatitis, pruritus, itching, or whatsoever allergic reactions causing skin rashes
Very young and very former individuals – extremes in historic period are associated to frail and sensitive skin
Presence of edema
Fecal and/or urinary incontinence
History of having radiation treatment
Having hyperthermia or hypothermia
Malnutrition
Immobility
Immunological deficit
Problems with blood apportionment
Impaired sensation
Long-term steroid use
Mechanical factors such as pressure, shear, and friction
Trauma such as scratches, pare tear, surgical incision
Obesity
Moisture build-upwardly

Dumb Skin Integrity Nursing Diagnosis

Impaired Skin Integrity Nursing Intendance Plan i

Kawasaki Disease

Nursing Diagnosis: Impaired skin integrity related to edema formation secondary to Kawasaki illness as evidenced past bilateral swelling of the legs and anxiety and small cutting on left ankle.

Desired issue: Patient will have healed left ankle wound and further skin damage will be prevented.

Impaired Skin Integrity Nursing Interventions	Rationales
Assess the skin for its integrity, color, moisture and texture.	Kawasaki affliction affects the peel and can cause erythematous rashes and edema particularly on the easily, arms, legs, and feet.
Assess the level of edema on the legs and cut on the ankle	Baseline data will assist in the evaluation of progress after interventions are made.
Encourage patient to elevate legs and avoid putting them on a dependent position for a long menstruation of time.	Putting legs on dependent position will worsen leg edema.
Encourage mobility	Physical activity helps promote circulation and fluid drainage.
Wearing apparel wounds as needed, avoiding tight, constricting, and sticky dressings.	Equally needed, wound will demand to be dressed and cleaned. Sticky dressings may be difficult to remove and cause further impairment.
Encourage patient to avoid wearing constricting article of clothing	Tight habiliment tin further irritate skin damage and rashes.
Encourage proper hydration	Dehydration can crusade further skin injury due to skin dryness.

Dumb Peel Integrity Nursing Care Programme 2

Diabetes

Nursing Diagnosis: Risk for impaired skin integrity due to decreased circulation from popliteal artery obstruction secondary to Type 2 diabetes

Desired outcome: Patient'southward pes will remain intact while waiting for vascular treatment

Impaired Skin Integrity Nursing Interventions	Rationales
Assess skin integrity taking note of colour, moisture, texture, and pulses regularly	Baseline data is needed for prompt evaluation later interventions are fabricated. Information technology will also help in the regular assessment in the progress of nursing intendance.
Encourage employ of footwear at all time	Diabetes tin impact sensation in the extremities. Patients may not notice injury.
Encourage daily moisturization of feet	Moisturizing feet everyday provides opportunity to appraise the integrity of the feet daily. Also, moisturizing the feet helps keep its intact skin integrity.
Bank check water temperature when washing anxiety	Patients may not find if the h2o is too hot due to reduced sensation.
Encourage patient to maintain brusque toenails	Long toenails tin cause damage to pare.
Discuss smoking cessation programs if the patient is a smoker	Vascular issues are worsened by smoking, besides, the success of vascular treatments such as angioplasty can exist affected if the patient volition non stop smoking after having information technology.
Monitor and maintain a normal blood saccharide level Hyperglycemia and hypoglycemia can both affect vascular wellness.
Review medications	Some medications used in type 2 diabetes tin predispose patients to foot bug though inquiry is nevertheless non conclusive on this matter.
Prepare patient for vascular treatment	Depending on the medical plan, the patient may accept to undergo surgical handling.

Impaired Skin Integrity Nursing Care Plan iii

Pressure ulcers / Bed sores

Nursing Diagnosis: Impaired skin integrity (pressure ulcers) secondary to decreased mobility as evidenced by presence of stage 2 pressure level ulcer on the sacrum.

Desired Event: Patient'south bedsore will show optimal healing, and further bedsores will exist prevented.

Impaired Skin Integrity Nursing Interventions	Rationales
Assess and record the integrity of skin	To provide baseline data to assess care.
Regularly assess status of bedsore	To regularly assess progress of healing
Promote regular turning or position modify	To forestall prolonged pressure on ane area of the body
Assess the ability of the patient to mobilize	To assess the extent of physical activities that the patient can do.
Provide appropriate mattress and cushion	Pressure release mattresses and cushions are helpful to prevent sores from occurring and they help spread equal pressure to the body when sitting and lying downwards.
Clean and apparel bedsore equally needed	Sacral sores are prone to infection due to its location.
Clean or assist patient in cleaning himself afterwards opening bowels	due to the location of bedsore, it can easily be reached past stool when bowels are opened.
Refer to physiotherapy	Physiotherapists can assist assess mobility and suggest on positioning and mobility aids
Change sheets regularly and avoid folds and creases.	Creases on sheets tin cause force per unit area on the pare.
Provide hurting relief as needed	Bedsores can exist uncomfortable for patients. Providing pain relief will aid encourage patients to mobilize and change position.

Dumb Skin Integrity Nursing Intendance Plan 4

Impetigo

Nursing Diagnosis: Impaired Peel Integrity related to infection of the skin secondary to impetigo, as evidenced by red sores around the expanse of the nose and mouth, discharge from the sores for a couple of days, development of yellowish-brownish chaff, balmy itching, pain and soreness

Desired Issue: The patient will re-establish salubrious skin integrity past following treatment regimen for impetigo.

Impaired Peel Integrity Nursing Interventions	Rationale
Appraise the patient's skin on his/her whole body.	To determine the severity of impetigo and any affected areas that crave special attention or wound care.
Isolate the patient in his/her room, at home ideally for 10 days.	Impetigo is an infectious/ catching peel disease. The patient needs to be isolated ideally for 7 to 10 days afterward starting treatment.
The affected surface area should be soaked showtime in warm h2o to remove the scabs, moisture compresses may also exist used. This is followed by the application of the prescribed antibody cream or ointment straight to the afflicted areas.	Removal of scabs prior to applying the topical antibiotic promotes good assimilation of the medication.
Administrate antibiotics as prescribed. Ensure that the patient finishes the course of antibiotic prescribed by the medico.	Impetigo is generally treated through the use of antibiotic therapy. If the infection is mild and have not spread to other areas of the body, the sores can exist treated through the use of over-the-counter antibiotic foam containing bacitracin, as a dwelling remedy. Awarding of non-stick bandages over the affected areas can also assistance prevent the spread of sores and further infection. The doctor may as well prescribe oral antibody drugs in patients who have a lot of impetigo sores. Even if the symptoms have already improved and healing is evident, it is all the same important to finish the course of antibiotic therapy to forestall recurrence of infection and antibiotic resistance.
Educate the patient and caregiver nearly proper wound hygiene through washing the sores with soap and water. Advise the patient and caregiver to prevent scratching the affected areas.	Information technology is important to maintain the cleanliness of the affected areas past washing with mild soap and water. The sores may crusade balmy itching, but information technology is advisable to forestall the child from scratching the afflicted areas to prevent worsening of the infection.
Teach the patient/ caregiver the proper application of non-stick bandages over the afflicted areas can besides assistance prevent the spread of sores and farther infection.	Proper application of non-stick bandages over the affected areas can also help prevent the spread of sores and further infection.

Dumb Skin Integrity Nursing Intendance Plan v

Necrotizing Fasciitis/ Skin Gangrene

Nursing Diagnosis: Dumb Peel Integrity related to infective procedure of necrotizing fasciitis as evidenced by positive tissue biopsy effect, gangrenous skin tissue, erythema, and pain on the afflicted site.

Desired Outcome: The patient will be able to experience optimal wound healing and avoid the spread of infection to the rest of the pare to preserve its integrity.

Impaired Skin Integrity Nursing Interventions	Rationales
Assess vital signs and monitor the signs of infection.	To establish baseline observations and cheque the progress of the infection every bit the patient receives medical treatment.
Gear up the patient for surgical debridement.	It involves the resection of the gangrenous tissue to prevent further spread of the condition to other vital organs. It involves extensive and consummate removal of expressionless tissue fifty-fifty beyond the area of necrosis.
Place silver-containing dressings on the affected site/south afterward each debridement.	Dressings containing silver compounds are helpful in addressing topical and direct antibiotic treatment of the affected tissues.
Administrate the prescribed antibiotics.	To treat the underlying bacterial crusade of necrotizing fasciitis.
Encourage proper hand hygiene and skin care.	To preserve integrity to the rest of the pare.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, 1000. (2020). Nursing diagnoses handbook: An testify-based guide to planning care . St. Louis, MO: Elsevier. Buy on Amazon

Gulanick, M., & Myers, J. 50. (2022). Nursing care plans: Diagnoses, interventions, & outcomes . St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. Yard. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care . St. Louis, MO: Elsevier. Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination . St. Louis, MO: Elsevier. Buy on Amazon

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This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.