Inspect patient's skin every shift; document skin condition and report status changes. Early detection of changes prevents or minimizes skin breakdown.- Monitor any wounds and surrounding tissue. Allows for individualized care.
- Monitor placement of tubing and devices. Correct placement and frequent inspection of devices prevent skin breakdown.
- Evaluate need for specialty pressure redirecting devices. Pressure redirecting devices help to eliminate pressure points on skin and tissue.
- Provide scrupulous foot care. Administer and monitor treatments according to institutional protocols. Foot care prevents fungal infections and ingrown toenails, stimulates circulation, and allows detection of signs and symptoms you should immediately report to the physician.
Instruct patient to avoid pressure on popliteal space. For example, say “Don't cross your legs or wear constrictive clothing” to avoid reducing arterial blood supply and increasing venous congestion.- Encourage exercise as tolerated. Exercise improves arterial circulation and venous return by promoting muscle contraction and relaxation.
- Educate patient about risk factors and prevention of injury. Refer patient to a smoking cessation program. Teaching about factors influencing peripheral vascular disease and prevention of tissue damage help prevent complications.
- Maintain adequate hydration. Monitor intake and output and record daily weight. Adequate hydration reduces blood viscosity and decreases the risk of clot formation.
Identify and document factors that predispose patient to impaired tissue integrity. A complete nursing assessment allows the development of an individualized care plan.
Suggested NIC Interventions
Electrolyte Monitoring; Fluid Monitoring; Nutrition Management; Positioning; Pressure Ulcer Prevention; Skin Surveillance |