- Extremes of age
- Immobility
- Poor nutrition
- Mechanical forces (pressure, shear, friction)
- Pronounced bony prominences
- Poor circulation
- Altered sensation
- Incontinence
- Edema
- Environmental moisture
- History of radiation
- Hyperthermia or hypothermia
- Acquired immunodeficiency syndrome (AIDS)
Patient’s Diagnosis: –
Date:-
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- Patient’s skin will remains intact, as evidenced by: no redness over bony prominences, and capillary refill less than 6 seconds over areas of redness.
- Others
Note: you need to indicate time frame/target as objective must be measurable.
| Nursing Interventions | Scientific Rationale |
|---|---|
| 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, and have quick capillary refill (less than 6 seconds). |
| Specifically assess skin over bony prominences (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 (mattress, chair, or table) and the bone. |
| Assess patient's awareness of the sensation of pressure. | 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 (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 greater than 2.5 g/100 ml is a grave sign, indicating severe protein depletion. |
| 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 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. |
| Assess for environmental moisture (wound drainage, high humidity). | That may contribute to skin maceration. |
| Assess surface that patient spends majority of time on (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. |
| 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. | To reduce friction. |
| 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. |
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