XII.

NURSING CARE PLAN – Risk for Impaired skin integrity (potential)

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Risk for impaired Within 1 hour of Independent: After 1 hour of

skin integrity nursing 1. Inspect patient’s skin every shift. Document nursing
related to physical intervention and skin condition. intervention
immobilization. health R: to early detection of changes, prevents or and health
teachings, the maximizes skin breakdown. teachings, the
client and the client and the
S/O will be able 2. Advice the S/O to position at least every S/O was able
to understand 2hours and follow turning schedule posted at to understand
preventive bedside. preventive
measures and R: to reduce pressure on tissue. measures and
treatments. treatments.
3. Encourage ambulation or perform or assist
with active ROM exercises atleast every 4
hours while patient is awake.
R: to prevent muscle atrophy and
contractures.

4. Use preventive skin care devices as

needed such as foam mattres, alternating
pressure mattres.
R: to avoid discomfort and skin breakdown.

5. Keep patient’s skin clean and dry and

lubricate as needed. Avoid use of irritating
soap and rinse skin well.
R: to alleviate skin dryness. Promote comfort
and reduce risk of irritation and skin
breakdown.

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