Assessment

Objective
Redness on bony
prominences

Planning
After 8 hours of nursing
intervention, the patient will
demonstrate behaviours or
techniques to prevent skin
breakdown.

Intervention
Assess skin daily. Note color, turgor, circulation,
and sensation. Describe and measure lesions
and observe changes. Take photographs if
necessary.

Scientific Rationale
Establishes comparative baseline providing
opportunity for timely intervention.

Impaired Skin Integrity

Maintaining clean, dry skin provides a barrier to

infection. Patting skin dry instead of rubbing
reduces risk of dermal trauma to dry and fragile
Maintain and instruct in good skin hygiene: wash
skin. Massaging increases circulation to the
thoroughly, pat dry carefully, and gently
skin and promotes comfort. Isolation
massage with lotion or appropriate cream.
precautions are required when extensive or
open cutaneous lesions are present.
Reposition frequently. Use turn sheet as needed.
Encourage periodic weight shifts. Protect bony
Reduces stress on pressure points, improves
prominences with pillows, heel and elbow
blood flow to tissues, and promotes healing.
pads, sheepskin.
Maintain clean, dry, wrinkle-free linen, preferably Skin friction caused by wet or wrinkled or rough
sheets leads to irritation of fragile skin and
soft cotton fabric.
increases risk for infection.
Encourage ambulation as tolerated.
Decreases pressure on skin from prolonged
bedrest.
Cleanse perianal area by removing stool with
water and mineral oil or commercial product.
Prevents maceration caused by diarrhea and
Avoid use of toilet paper if vesicles are
keeps perianal lesions dry. Use of toilet paper
present. Apply protective creams: zinc oxide, A
may abrade lesions.
& D ointment.
File nails regularly.

Long and rough nails increase risk of dermal

damage.

Cover open pressure ulcers with sterile dressings

or protective barrier: Tegaderm, DuoDerm, as May reduce bacterial contamination, promote
healing.
indicated.
Provide foam, flotation, alternate pressure
mattress or bed.

Reduces pressure on skin, tissue, and lesions,

decreasing tissue ischemia.

Obtain cultures of open skin lesions.

Identifies pathogens and appropriate treatment

choices.

Apply and administer medications as indicated.

Cover ulcerated KS lesions with wet-to-wet

dressings or antibiotic ointment and nonstick

Used in treatment of skin lesions. Use of agents

such as Prederm spray can stimulate
circulation, enhancing healing process. When
multidose ointments are used, care must be
taken to avoid cross-contamination.

Evaluation
After 8 hours of
nursing
intervention, the
patient was able
to demonstrate
behaviours and
techniques to
prevent skin
breakdown.