Nursing Care Nursing Diagnosis: Risk for Impaired Skin

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Pressure Sores; Pressure Ulcers; Bed Sores; Decubitus Care
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NOC Outcomes (Nursing Outcomes Classification)
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Suggested NOC Labels
Impaired Skin
Integrity Risk Control
Ongoing Risk Detection
Assessment Tissue Integrity: Skin and Mucous Membranes
Therapeutic
Interventions
NIC Interventions (Nursing Interventions Classification)
Education/
Continuity of Suggested NIC Labels
Care
Pressure Ulcer Prevention
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Diagnosis

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NANDA Definition: At risk for skin being adversely altered
Care Plan

Start New Immobility, which leads to pressure, shear, and friction, is the factor most likely to put
Care Plan an individual at risk for altered skin integrity. Advanced age; the normal loss of
elasticity; inadequate nutrition; environmental moisture, especially from incontinence;
Instructions and vascular insufficiency potentiate the effects of pressure and hasten the
development of skin breakdown. Groups of persons with the highest risk for altered
skin integrity are the spinal cord injured, those who are confined to bed or wheelchair
for prolonged periods of time, those with edema, and those who have altered sensation
that triggers the normal protective weight shifting. Pressure relief and pressure
reduction devices for the prevention of skin breakdown include a wide range of
surfaces, specialty beds and mattresses, and other devices. Preventive measures are
usually not reimbursable, even though costs related to treatment once breakdown
occurs are greater.

Risk Factors:
Extremes of age
Immobility
Poor nutrition
Mechanical forces (e.g., pressure, shear, friction)
Pronounced bony prominences
Poor circulation
Altered sensation
Incontinence
Edema
Environmental moisture
History of radiation
Hyperthermia or hypothermia
Acquired immunodeficiency syndrome (AIDS)
 Expected Outcomes
Patient’s skin remains intact, as evidenced by no redness over bony prominences
and capillary refill less than 6 seconds over areas of redness.

Ongoing Assessment

Determine age. Elderly patients’ skin is normally less elastic and has less
moisture, making for higher risk of skin impairment.
Assess general condition of skin. Healthy skin varies from individual to
individual, but should have good turgor (an indication of moisture), feel
warm and dry to the touch, be free of impairment (scratches, bruises,
excoriation, rashes), and have quick capillary refill (<6 seconds).
Specifically assess skin over bony prominences (e.g., sacrum, trochanters,
scapulae, elbows, heels, inner and outer malleolus, inner and outer knees, back
of head). Areas where skin is stretched tautly over bony prominences are
at higher risk for breakdown because the possibility of ischemia to skin is
high as a result of compression of skin capillaries between a hard surface
(e.g., mattress, chair, or table) and the bone.
Assess patient’s awareness of the sensation of pressure. Normally,
individuals shift their weight off pressure areas every few minutes; this
occurs more or less automatically, even during sleep. Patients with
decreased sensation are unaware of unpleasant stimuli (pressure) and do
not shift weight. This results in prolonged pressure on skin capillaries, and
ultimately, skin ischemia.
Assess patient’s ability to move (e.g., shift weight while sitting, turn over in
bed, move from bed to chair). Immobility is the greatest risk factor in skin
breakdown.
Assess patient’s nutritional status, including weight, weight loss, and serum
albumin levels. An albumin level less than 2.5 g/dl is a grave sign,
indicating severe protein depletion. Research has shown that patients
whose serum albumin is less than 2.5 g/dl are at high risk for skin
breakdown, all other factors being equal.
Assess for edema. Skin stretched tautly over edematous tissue is at risk
for impairment.
Assess for history of radiation therapy. Radiated skin becomes thin and
friable, may have less blood supply, and is at higher risk for breakdown.
Assess for history or presence of AIDS. Early manifestations of HIV-related
diseases may include skin lesions (e.g., Kaposi’s sarcoma); additionally,
because of their immunocompromise, patients with AIDS often have skin
breakdown.
Assess for fecal and/or urinary incontinence. The urea in urine turns into
ammonia within minutes and is caustic to the skin. Stool may contain
enzymes that cause skin breakdown. Use of diapers and incontinence pads
with plastic liners traps moisture and hastens breakdown.
Assess for environmental moisture (e.g., wound drainage, high humidity).
Moisture may contribute to skin maceration.
Assess surface that patient spends majority of time on (e.g., mattress for
bedridden patient, cushion for persons in wheelchairs). Patients who spend the
majority of time on one surface need a pressure reduction or pressure
relief device to distribute pressure more evenly and lessen the risk for
breakdown.
Assess amount of shear (pressure exerted laterally) and friction (rubbing) on
patient’s skin. A common cause of shear is elevating the head of the
patient’s bed: the body’s weight is shifted downward onto the patient’s
sacrum. Common causes of friction include the patient rubbing heels or
 elbows against bed linen, and moving the patient up in bed without the
use of a lift sheet.
Reassess skin often and whenever the patient’s condition or treatment plan
results in an increased number of risk factors. The incidence and onset of skin
breakdown is directly related to the number of risk factors present.

Therapeutic Interventions

If patient is restricted to bed:

Encourage implementation and posting of a turning schedule, restricting
time in one position to 2 hours or less and customizing the schedule to
patient’s routine and caregiver’s needs. A schedule that does not
interfere with the patient’s and caregivers’ activities is most likely to
be followed.
Encourage implementation of pressure-relieving devices commensurate with
degree of risk for skin impairment:
For low-risk patients: good-quality (dense, at least 5 inches thick) foam
mattress overlay Egg crate mattresses less than 4 to 5 inches thick do
not relieve pressure; because they are made of foam, moisture can
be trapped. A false sense of security with the use of these
mattresses can delay initiation of devices useful in relieving
pressure.
For moderate risk patients: water mattress, static or dynamic air mattress
In the home, a waterbed is a good alternative.
For high-risk patients or those with existing stage III or IV pressure sores
(or with stage II pressure sores and multiple risk factors): low-air-loss beds
(Mediscus, Flexicare, Kinair) or air-fluidized therapy (Clinitron, Skytron)
Low-air-loss beds are constructed to allow elevated head of bed
(HOB) and patient transfer. These should be used when pulmonary
concerns necessitate elevating HOB or when getting patient up is
feasible. "Air-fluidized" therapy supports patient’s weight at well
below capillary closing pressure but restricts getting patient out of
bed easily.
Encourage patient and/or caregiver to maintain functional body alignment.
Limit chair sitting to 2 hours at any one time. Pressure over sacrum may
exceed 100 mm Hg pressure during sitting. The pressure necessary to
close skin capillaries is around 32 mm Hg; any pressure greater than 32
mm Hg results in skin ischemia.
Encourage ambulation if patient is able.
Increase tissue perfusion by massaging around affected area. Massaging
reddened area may damage skin further.
Clean, dry, and moisturize skin, especially over bony prominences, twice daily
or as indicated by incontinence or sweating. If powder is desirable, use medical-
grade cornstarch; avoid talc.
Encourage adequate nutrition and hydration:
2000 to 3000 kcal/day (more if increased metabolic demands).
Fluid intake of 2000 ml/day unless medically restricted. Hydrated skin is
less prone to breakdown. Patients with limited cardiovascular
reserve may not be able to tolerate this much fluid.
Encourage use of lift sheets to move patient in bed and discourage patient or
caregiver from elevating HOB repeatedly. These measures reduce shearing
forces on the skin.
Leave blisters intact by wrapping in gauze, or applying a hydrocolloid
(Duoderm, Sween-Appeal) or a vapor-permeable membrane dressing (Op-Site,
Tegaderm). Blisters are sterile natural dressings. Leaving them intact
 maintains the skin’s natural function as barrier to pathogens while the
impaired area below the blister heals.

Education/Continuity of Care

Consult dietitian as appropriate.

Teach patient and caregiver the cause(s) of pressure ulcer development:
Pressure on skin, especially over bony prominences
Incontinence
Poor nutrition
Shearing or friction against skin
Reinforce the importance of mobility, turning, or ambulation in prevention of
pressure ulcers.
Teach patient or caregiver the proper use and maintenance of pressure-
relieving devices to be used at home.

Include Rationales?
Create the Care Plan

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