Introduction to Nursing Care Plan for Risk for Impaired Skin Integrity
Skin, the largest organ of our body, is an important barrier that helps protect the overall integrity of the body from injury and infection. Therefore, it is essential to ensure good skin integrity by monitoring it regularly in order to avoid any risks of impaired skin integrity. In this article, we discuss nursing care plan for risk for impaired skin integrity that involves assessment, diagnosis, outcomes, interventions, rationales, evaluation, conclusion and a list of frequently asked questions.
The nurse should assess the presence of risk factors that might lead to impaired skin integrity such as:
- Patient’s condition: This includes the patient’s age, physical condition, occupation, mental status, nutrition and overall health.
- Pressure ulcer risk factors: This includes pressure, friction, shear, incontinence and malnourishment.
- Intactness of skin: This includes signs of reddening, irritation, dryness or wound on skin.
- Environmental factors: This includes inadequate bedding, low humidity, poor nutrition, poor functioning of internal organs, etc.
After assessing the risk factors that may lead to skin problems, a nursing diagnosis is made. The nursing diagnosis can be as follows:
- Ineffective Protection Related To : This may include weakened skin structure, physical impairment, prolonged synthetic fibres resulting in inadequate protection against microbes.
- Risk for Infection: This may include contamination of damaged skin, presence of lesions and injury.
- Risk for Impaired Skin Integrity: This may include risk factors such as inadequate nutrition, immobility, pressure or friction with external surfaces.
Once the nursing diagnosis is made, the nurse should set certain outcomes. The outcomes should be measurable and achievable so they can be evaluated to determine whether the desired changes have been made. Some of the following outcomes can be set:
- Patient safety: Patient should be able to attain safety by maintaining intra-and extra-cellular environment.
- Healing of wounds: Wounds should heal properly and the patient should not fall prey to infection.
- Reduction in pain: Patient should feel no pain from skin damage.
- Prevention of further damage: There should be no further damage to the skin.
The nurse should come up with some effective nursing interventions to reduce the risk of impaired skin integrity. These interventions can be as follows:
- Assess skin integrity: It is important to regularly inspect the patient’s skin to identify any early signs of skin breakdown.
- Provide adequate nutrition: The patient should have adequate and balanced nutrition in order to maintain a healthy skin.
- Maintain skin moisture: Moisturizers such as creams, lotions and oils should be used to restore skin elasticity and maintain skin moisture.
- Reduce exposure to external irritants: Exposure to environmental irritants such as urine and feces should be minimized.
- Maintain regular skin cleansing: Proper skin cleansing and drying should be done to avoid skin infection.
The nurse must explain why the interventions chosen are effective and necessary. The rationales for the selected interventions can be as follows:
- Assess skin integrity: This will help detect any early signs of skin breakdown and enable early intervention, which will minimize further deterioration of the skin.
- Provide adequate nutrition: Nutritional deficiencies can lead to impaired skin integrity, hence it is important to provide adequate and balanced nutrition.
- Maintain skin moisture: Keepin=g the skin hydrated helps restore skin elasticity and makes the skin more resistant to wounds, abrasions, and other forms of skinDamage.
- Reduce exposure to external irritants: Prolonged exposure to environmental irritants can lead to skin breakdown and skin infection.
- Maintain regular skin cleansing: Proper skin cleansing and drying helps minimize the risk of skin infection.
The nurse should evaluate the effectiveness of the nursing interventions by assessing the patient’s response to the interventions. The nurse should measure the patient’s pain level, assess the wound healing rate, and check for other signs of improvement in skin integrity.
In conclusion, nursing care plan for risk for impaired skin integrity is an important aspect of providing quality care to patients. It involves various assessment steps, diagnosis, outcomes, interventions and rationales as described above. The nurse should also evaluate the effectiveness of the interventions in terms of an improvement in the patient’s skin integrity.
- What is a nursing care plan for risk for impaired skin integrity?
A nursing care plan for risk for impaired skin integrity is a plan or strategy formulated by nurses in order to reduce the risk of impaired skin integrity. This plan involves assessment, nursing diagnosis, outcomes, interventions and rationales.
- How is the skin assessed for risk for impaired skin integrity?
The nurse should assess the presence of risk factors that might lead to impaired skin integrity such as patient’s condition, pressure ulcer risk factors, intactness of skin and environmental factors.
- What are the interventions for risk for impaired skin integrity?
The nurse should come up with some effective nursing interventions to reduce the risk of impaired skin integrity. These interventions include: ass