Nursing Diagnosis Risk For Impaired Skin Integrity

Need A C T I V I T Y
Nursing Diagnosis
Objective of Care
Nursing Intervention
Risk for Impaired Skin Integrity Related Extremes of Age. Rationale: Immobility, which leads to pressure, shear, and friction, is the factor most likely to put an individual at risk for altered skin integrity. Older patients skin is normally elastic and has
That within our 8 hours patient would be able to: A. Patients skin remains intact as evidenced by: Capillary Refill time of 3 or less than 3 seeconds. Absence of pressure ulcer. B. Verbalize the importance of preventive measures.
1. Reassess patients skin condition R = to know the extent of the damage. 2. Change the patients position frequently when at bed. R = Position changes relieve pressure, restore blood flow, and promote skin integrity. 3. Use pressure-relieving beds, mattress overlays, and chair cushions. R = Theses devices redistribute pressure when frequent position changes are not possible. 4. Apply lotion if not contraindicated. R = these prevent friction and shear. 5. Encourage to wear cotton fabric clothes. R = skin friction caused by stiff or rough clothes leads to irritation. 6. Emphasize the importance of adequate nutrition and oral fluid intake. R = improve nutrition and hydration will improve skin condition. 7. Encourage ambulation R = Ambulation reduces pressure on the skin from immobility. 8. Increase tissue perfusion by massaging around the affected area. R = massaging the actual reddened area may damage the skin further. 9. Limit chair sitting to 2 hours at any one time and encourage patient to shift weight every 15 minutes. R = pressure ober the sacrum may exceed 100mmHg pressure during sitting. The pressure necessary to close skin capillaries is aroung 32mmHg any pressure greater then 32 mmHg may result to ischemia
to span on nursing care our
E X E R C I S E
P A T T E R N
less moisture, making for higher risk of skin impairment.
My sister has been diagnosed with frontotemporal dementia. She is 57 years old. In August 2008 she didn't show up for work, and when I went to her home I discovered that she had started hoarding. I had not been to her house in several years. Whenever I went there she would meet me outside and would not invite me in. I found her inside lying on her bed in the same clothes as the day before. No sheets on the bed, and lying in urine. After we arrived at the hospital I asked them to run an MRI because she had had a brain tumor in 1988. After the MRI was examined I was told that she had a head trauma from a car accident. I knew she hadn't and kept pressing for more tests. They ran a CT scan and then another neurologist looked at her MRI and saw the disease. This has nothing to do with the brain tumor. She began forgetting to go work, getting angry at other drivers when driving, forgetting to pay bills and having crying episodes at work. In January she had an incident at work where she got mad and threw a box at someone. After that we had to put her on disability and take away her driving privileges. This has been hard for her to understand because she thinks she is fine. The hardest part for me was telling the doctors (in front of her) what was going on. This is only the beginning I know and I must find the courage to talk to her about plans for her future. I am her only sister. My brother helps but can do only so much. My parents are 80 and 81 and they are in better health than my sister. It has been 8 months, and I finally have her house clean. The dementia itself is enough to deal with. Now I also have to take care of her financial and medical decisions. I make sure that I still make the time to enjoy my 3 grandchildren and go away periodically with my husband and do nothing. Absolutely nothing. Right now she is at the point where she is child like and does not want to bathe, brush her teeth or go to bed. What comes next?
AUTHOR: Karen Loise SOURCE: Medscape URL: http://medscape.ucsf.edu/ftd/community-support/personal-stories/Karen

Nursing Diagnosis Risk For Impaired Skin Integrity

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Need A C T I V I T Y

to span on nursing care our

less moisture, making for higher risk of skin impairment.

AUTHOR: Karen Loise SOURCE: Medscape URL: http://medscape.ucsf.edu/ftd/community-support/personal-stories/Karen

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