Inspect patient's skin every 8 hours, describe and document skin condition, and report changes to provide evidence of the effectiveness of skin care regimen. 
Perform prescribed treatment regimen for the skin condition involved; monitor progress. Report favorable and adverse responses to treatment regimen to maintain or modify current therapies, as needed.- Maintain infection control standards to help minimize the risk of nosocomial infections.
- Provide supportive measures, as indicated:
- Assist with general hygiene and comfort measures to promote comfort and general sense of well-being.
- Administer pain medications and monitor effectiveness. Patient needs pain relief to maintain health.
- Maintain proper environmental conditions, including room temperature and ventilation. Providing a comfortable environment promotes sense of well-being.
- Apply a bed cradle to protect lesions from bed covers.
- Remind patient not to scratch to avoid skin injury.
- Administer and monitor effectiveness of antipruritic medications. Antipruritics reduce itching sensation.
- Explain dietary restrictions; for example, explain that certain foods may cause a skin allergy. Avoiding foods that cause skin allergy helps prevent skin breakdown.
Encourage patient to express feelings about skin condition to enhance coping.- Position patient for comfort and minimal pressure on bony prominences. Change patient's position at least every 2 hours. Monitor frequency of turning and skin condition. These measures reduce pressure, promote circulation, and minimize skin breakdown.
- Discuss precipitating factors, if known, and long-term effects of skin integrity interruption. Knowledge of precipitating factors helps patient reduce their occurrence and severity.
- Follow facility protocol for treatment of pressure ulcer or surgical wound care to ensure provision of appropriate care.
- Instruct patient and family in the skin care regimen to ensure compliance.
- Supervise patient and family in the skin care regimen. Provide feedback. Practice helps improve skill in managing patient's skin care regimen.
- Encourage adherence to other aspects of health care management to control or minimize effects on skin.
Refer patient to a psychiatric liaison nurse, social service, or support group, as appropriate. These resources provide additional support for patient and family.
Suggested NIC Interventions
Infection Control; Nutrition Therapy; Positioning; Pressure Ulcer Prevention; Skin Surveillance |