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Care Plan: Skin Integrity Cheat Sheet by

Care Plan: Skin Integrity
medical     care     temporary     integrity     healthcare     skin     plan-

Introd­uction

What should be on our temporary care plan for skin integrity?

First, ensure your temporary plan of care is completed within 48 hours of admission.

The skin integrity care plan interv­entions should be indivi­dua­lized and based on the results of the skin inspection and skin integrity risk assess­ment. However, there are some interv­entions that always should be considered on the temporary skin integrity plan of care:

Interv­entions

Pressu­re-­red­ist­rib­ution mattress
Pressu­re-­red­ist­rib­ution wheelchair cushion
Turning and reposi­tioning schedule and devices
For immobile residents, a means of elevating the heelsof the bed
Incont­inence manage­ment, with skin kept clean and dry
Referrals as approp­riate to Dietary and Therapy
Daily monitoring of the skin condition by caregivers
Head-t­o-toe weekly skin check performed by licensed nurses
Skin integrity risk assessment per policy
Staff reporting of all skin concerns to the nurse
Notifi­cation of the physic­ian/NP and family­/de­signee of any skin concerns that are found

Wound Present? Yes

At a minimum Address the following:
Topical treatment as ordered
Weekly wound assessment by licensed nurses
Monitoring of the wound for signs and symptoms of infection or decline
Notifi­cation of the physic­ian/NP and family­/de­signee of any decline, changes in treatment, or concerns.
Once the temporary plan of care is developed, ensure the inform­ation is properly commun­icated and placed on the nursing assist­ants' care sheets.

Elements of a Compre­hensive Skin Assessment

Back­gro­und: This sheet summarizes the elements of a correct compre­hensive skin assess­ment. You could, for example, integrate them into your docume­ntation system or use this sheet for staff training.
Reference: Developed by Boston University Research Team.

Skin Temper­ature

1. Most clinicians use the back rather than the palm of their hand to assess the temper­ature of a patient's skin.
2. Remember that increased skin temper­ature can be a sign of fever or impending skin problems such as a Stage I pressure ulcer or a diabetic foot about to ulcerate.
3. Touch the skin to evaluate if it is warm or cool.
4. Compare symmet­rical body parts for differ­ences in skin temper­ature.
 

Skin Care

Skin Color

1. Ensure that there is adequate light.
2. Use an additional light source such as a penlight to illuminate hard to see skin areas such as the heels or sacrum.
3. Know the person's normal skin tone so that you can evaluate changes.
4. Look for differ­ences in color between comparable body parts, such as left and right leg.
5. Depress any discolored areas to see if they are blanchable or nonbla­nch­able.
6. Look for redness or darker skin tone, which indicate infection or increased pressure.
7. Look for paleness, flushing, or cyanosis.
8. Remember that changes in coloration may be partic­ularly difficult to see in darkly pigmented skin.

Skin Moisture

1. Touch the skin to see if the skin is wet or dry, or has the right balance of moisture.
2. Remember that dry skin, or xerosis, may also appear scaly or lighter in color.
3. Check if the skin is oily.
4. Note that macerated skin from too much moisture may also appear lighter or feel soft or boggy.
5. Also look for water droplets on the skin. Is the skin clammy?
6. Determine whether these changes localized or genera­lized.

Skin Turgor

1. To assess skin turgor, take your fingers and "­pin­ch" the skin near the clavicle or the forearm so that the skin lifts up from the underlying structure. Then let the skin go.
2. If the skin quickly returns to place, this is a normal skin turgor finding.
3. If the skin does not return to place, but stays up, this is called "­ten­tin­g," and is an abnormal skin turgor finding.
4. Poor skin turgor is sometimes found in persons who are older, dehydr­ated, or edematous, or have connective tissue disease.

Skin Integrity

1. Look to see if the skin is intact without any cracks or openings.
2. Determine whether the skin is thick or thin.
3. Identify signs of pruritis, such as excori­ations from scratc­hing.
4. Determine whether any lesions are raised or flat.
5. Identify whether the skin is bruised.
6. Note any disrup­tions in the skin.
7. If a skin disruption is found, the type of skin injury will need to be identi­fied.
Since there are many different etiologies of skin wounds and ulcers, differ­ential diagnosis of the skin problem will need to be determ­ined. For example is it a skin tear, a pressure ulcer, or moistu­re-­ass­ociated skin damage or injury?

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