Impaired Skin Integrity

Assessment

Subjective:

Objective:
- (+) HIV infection
- Rash characterized
by erythematous
plaques and
overlying white
scale involving the
face, abdomen,
arms, legs, feet,
and hands,
including palms

Diagnosis

Impaired skin
integrity evident by
skin rashes secondary
to syphillis

Nursing Intervention

Independent:
1. Assess skin daily. Note color, turgor, circulation,
and sensation. Describe and measure lesions and
observe changes. Take photographs if necessary.
2. Assess bony prominences, perineum, and
dependent and pruritic areas for pallor, redness,
and breakdown.
3. Maintain and instruct in good skin hygiene:
wash thoroughly, pat dry carefully, and gently
massage with lotion or appropriate cream.
4. Maintain clean, dry, wrinkle-free linen,
preferably soft cotton fabric.
5. Position client properly; use pressure-reducing
or pressure-relieving devices
6. Instruct or assist client to shift weight at least
every 30 minutes
7. Encourage ambulation as tolerated.
8. File nails regularly.
9. Apply and administer medications as indicated.

10. If tissue breakdown occurs notify appropriate

health care provider

Collaborative:
1. Administer prescribed antibiotics (IV penicillin)
2. Administer prescribed Glucocorticoid
(prednisone) for inflammation
4. Assist in procedures
3. Collaborate with other involved health care
team members

Assessment

Diagnosis

Nursing Intervention

Subjective:

Objective:
- (+) HIV infection
- Rash characterized
by erythematous
plaques and
overlying white
scale involving the
face, abdomen,
arms, legs, feet,
and hands,
including palms

Impaired skin
integrity evident by
skin rashes secondary
to syphillis

Independent:
1. Assess skin daily. Note color, turgor,

circulation, and sensation. Describe and

measure lesions and observe changes. Take
photographs if necessary.
2. Maintain and instruct in good skin
hygiene: wash thoroughly, pat dry
carefully, and gently massage with lotion or
appropriate cream.
3. Maintain clean, dry, wrinkle-free linen,
preferably soft cotton fabric.
4. Encourage ambulation as tolerated.
5. File nails regularly.
6. Apply and administer medications as
indicated.
Collaborative:
1. Administer prescribed antibiotics (IV penicillin)
2. Administer prescribed Glucocorticoid
(prednisone) for inflammation
4. Assist in procedures
3. Collaborate with other involved health care

team members