Nursing Diagnosis

Patient Outcomes

Nursing Interventions

Rationale

Evaluation

Impaired Skin Integrity

Related Factors:
1. Age
2. Immobility
3. Friction or shear
4. poor circulation
5. moisture
6. chronic disease
state
Evidenced by:
1. Redness
2. Blisters
3. Open lesion involving
the dermis
4. open lesion which
involves bones or
joint
5. drainage of pus

1. The patient will be

able to receive proper
medical attention
before it gets worse.
2. The patient will be
able to manifest signs
of healing and
reduction of pressure
ulcers.
3. The patient will be
able to prevent future
pressure ulcer

1. Introduce yourself at the start

of the nursing care.

1. This will establish trust in the

working phase.

2. Determine the risk factors

leading to pressure ulcer
formation:
age
disease
mobility

2. Elderly patients is less elastic and has

less moisture making it more prone to
skin impairment.

Please refer
to the Patient
Outcomes tab

3. Observe the skin integrity on

the bony prominences.
4. Apply prescribed dressing
such as hydrocolloid dressing.
5. Prevent over exposure to
moisture such as from urine or
perspiration.
6. Observe sterile technique in
doing procedures.
7. Hydrate the patient and
encourage intake of foods rich in
Vitamin C and protein.

3. The areas were the skin is stretched

are as follows: sacrum. Trochanters,
scapulae, elbows. These are the areas
were the highest skin breakdown are.
There is a possibility of skin ischemia
due compression of blood vessels.
4. This composition will prevent friction
or shear. Another way is to provide
emollient to skin to moisturize the skin.
5. This can prevent accumulation of
bacteria thereby keeping away from
infection.
6. Foreign body can also affect greatly
the capability of the skin to regenerate.
Keeping the area clean and free from
excessive moisture can lead to faster
healing process.
7. Collagen can come from Vitamin C,
eating lots of food rich in Vitamin C can
replace the lost collagen thereby leading
to faster healing process.