Inspect patient's skin every shift; document skin condition and report status changes. Early detection of changes prevents or minimizes skin breakdown.- Change patient's position at least every 2 hours; follow turning schedule posted at bedside. Monitor frequency of turning. These measures reduce pressure on tissues, promote circulation, and help prevent skin breakdown.
- Encourage ambulation or perform or assist with active ROM exercises at least every 4 hours while patient is awake. Exercises prevent muscle atrophy and contracture; ambulation promotes circulation and relieves pressure.
- Use preventive skin care devices, as needed, such as a foam mattress, alternating pressure mattress, sheepskin, pillows, and padding, to avoid discomfort and skin breakdown.
Keep patient's skin clean and dry; lubricate, as needed. Don't use irritating soap, and rinse skin well. These measures alleviate skin dryness, promote comfort, and reduce the risk of irritation and skin breakdown.- Protect bony prominences with foam padding. Prominences have little subcutaneous fat and are prone to breakdown; using foam padding may help promote skin integrity.
- Lift patient's body when moving the patient, using a lifting sheet, if needed. Avoid shearing force. Shearing force results when tissues slide against each other; a lifting sheet reduces sliding.
- Keep linen dry, clean, and free from wrinkles or crumbs. Change wet bed linens and incontinence pads immediately. Dry, smooth linens help prevent excoriation and skin breakdown.
- Monitor nutritional intake; maintain adequate hydration. Anemia (<10 mg hemoglobin) and low serum albumin concentrations (<2 mg) are associated with the development of pressure ulcers. Hydration helps maintain skin integrity.
- Teach patient about the need for good nutrition, including the importance of meeting caloric requirements and benefits of adequate vitamin and protein intake. Good nutrition helps maintain adequate tissue nourishment, perfusion, and oxygenation.
- Educate patient and family in preventive skin care. Teach them how to maintain good personal hygiene; use nonirritating (nonalkaline) soap; pat rather than rub skin dry; inspect skin regularly; avoid prolonged exposure to water, sun, cold, and wind; avoid rubber rings; recognize the beginning of skin breakdown (redness, blisters, and discoloration); and report signs and symptoms. These measures encourage compliance with patient's skin care regimen.
- Indicate the risk factor potential on patient's chart and care plan, and reevaluate weekly, using an accepted form such as the Braden Scale. The risk factor score helps evaluate treatment progress.
Explain the importance of practicing preventive skin care measures to encourage compliance with skin care regimen.- Supervise patient and family in preventive skin care measures. Give constructive feedback. Practice helps improve skill in managing the skin care regimen.
Suggested NIC Interventions
Circulatory Precautions; Infection Prevention; Positioning; Pressure Management; Pressure Ulcer Prevention; Skin Surveillance; Splinting |