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Clients at Risk For or With Impaired Skin Integrity: Identifying Nursing Diagnoses, Outcomes, and Interventions

This document discusses skin integrity and wound care for patients at risk. It provides two case studies, one of an elderly woman at risk of skin breakdown due to incontinence and immobility, and the other of a man with a stage II pressure ulcer on his heel. For each case, nursing diagnoses, desired outcomes, and sample interventions are identified. These include positioning the first patient, applying protective barriers, and cleaning and dressing the second patient's wound. The document also discusses factors to assess for home wound care, such as a patient's mobility, wound care abilities, nutrition, caregiver support, and community resources.

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Alif Akbar Hasyimi
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1K views1 page

Clients at Risk For or With Impaired Skin Integrity: Identifying Nursing Diagnoses, Outcomes, and Interventions

This document discusses skin integrity and wound care for patients at risk. It provides two case studies, one of an elderly woman at risk of skin breakdown due to incontinence and immobility, and the other of a man with a stage II pressure ulcer on his heel. For each case, nursing diagnoses, desired outcomes, and sample interventions are identified. These include positioning the first patient, applying protective barriers, and cleaning and dressing the second patient's wound. The document also discusses factors to assess for home wound care, such as a patient's mobility, wound care abilities, nutrition, caregiver support, and community resources.

Uploaded by

Alif Akbar Hasyimi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Case Studies on Nursing Diagnoses: This section provides detailed case studies focusing on nursing diagnoses, outcomes, and interventions for different patient scenarios with impaired skin integrity.

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CHAPTER 36 / Skin Integrity and Wound Care 917

IDENTIFYING NURSING DIAGNOSES, OUTCOMES, AND INTERVENTIONS


Clients At Risk for or With Impaired Skin Integrity
DATA CLUSTER Juanita Perez, an 85-year-old, is pale, emaciated, and listless. Weight 90 lb. is incontinent of urine and stool, and is bedridden.

NURSING SAMPLE DESIRED SELECTED


DIAGNOSIS/ OUTCOMES*/ INTERVENTIONS*/
DEFINITION DEFINITION INDICATORS DEFINITION SAMPLE NIC ACTIVITIES
Risk for Impaired Skin In- Tissue Integrity: Skin Mildly compro- Positioning ■ Explain to the client that she is going
tegrity related to inconti- and Mucous Mem- mised [0840]/Deliberative to be turned (and how often)
nence and immobility/ branes [1101]/ ■ Elasticity.
placement of the pa- ■ Position in proper body alignment
At risk for skin being ad- Structural intactness None tient or a body part to ■ Place on an appropriate therapeutic
versely altered and normal physiologi- ■ Skin lesions
promote physiological mattress or bed
cal function of skin and and/or psychological ■ Document skin status at least each
mucous membranes well-being. shift
Pressure Ulcer ■ Remove moisture from the skin
Prevention [3540]/ caused by urinary and fecal
Prevention of pressure incontinence
ulcers for an individual ■ Apply protective barriers such as
at high risk for devel- creams or pads to absorb excess
oping them moisture

DATA CLUSTER Matthew Brown, an obese 70-year-old hemiplegic, complains of discomfort in his left heel after attempting to move in bed.
Superficial skin abrasion 1.2 cm in diameter present at base of left heel.

Impaired Skin Integrity Wound Healing: Sec- Substantial Pressure Ulcer Care ■ Cleanse the skin around the ulcer
(stage II pressure ulcer) re- ondary Intention ■ Granulation [3520]/Facilitation of with mild soap and water at least daily
lated to friction/Altered [1103]/Extent of re- ■ Decreased healing in pressure ■ Note characteristics of any drainage
epidermis and/or dermis generation of cells and wound size ulcers ■ Ensure adequate nutrition
tissues in an open ■ Apply a transparent wound barrier
wound ■ Use devices on the bed that protect
the individual
*The NOC # for desired outcomes and the NIC # for nursing interventions are listed in brackets following the appropriate outcome or intervention. Outcomes, indicators, in-
terventions, and activities selected are only a sample of those suggested by NOC and NIC and should be further individualized for each client.

HOME CARE ASSESSMENT


Wound Care and Prevention of Pressure Ulcers
CLIENT AND ENVIRONMENT tion or treatment strategies; willingness to assist with wound care
■ Current level of knowledge: Understanding of the cause of the and actions to prevent pressure ulcers
wound or risk for developing a pressure ulcer; prevention or treat- ■ Family role changes and coping: Effect on financial status, parent-
ment strategies ing and spousal roles, sexuality, social roles
■ Self-care abilities for mobility: Physical ability to change position, ■ Alternate potential primary or respite caregivers: For example,
ambulate, and transfer including the use of assistive devices other family members, volunteers, church members, paid care-
■ Self-care abilities for wound care: Manual dexterity and visual acuity givers or housekeeping services; available community respite care
necessary to perform skin assessments and wound treatments (adult day care, senior centers, etc.)
■ Facilities: Presence of running water, garbage, bathroom needed COMMUNITY
to perform wound care and contain potentially infectious materials ■ Resources: Availability and familiarity with possible sources of as-
■ Current level of nutrition: Eating habits and preferences, labora- sistance such as equipment and supply companies, organizations
tory values indicating need for teaching or other intervention that offer medical supplies or financial assistance, home health
FAMILY agencies
■ Caregiver availability, skills, and responses: Understanding of the
cause of the wound or risk for developing a pressure ulcer; preven-

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