Damage to mucous membranes, corneal, integumentary, or subcutaneous tissues is referred to as skin integrity. This is the condition where the patient’s tissues are subject to ulcers or wounds that changes their nature and jeopardizes the patient’s health. Our skin is the body’s biggest organ and the first line of defense against external threats. But tissue integrity means that this primary defense mechanism is unable to do its job making our bodies more vulnerable to infections and harmful substances that can enter the bloodstream, travel throughout your patient’s body, and cause lots of damage.
A nursing care plan for skin integrity serves as a guideline that can help health care providers offer the best help to manage and prevent further damage, allowing a patient to recover. There are different formats that can be followed when you’re developing a nursing care plan. But its content is what really matters.
How to Write an Impaired Skin Integrity Care Plan?
For a nursing student, as well as a certified practicing nurse, there are a few factors that you should take into consideration while working on a nursing care plan. Failing to include some of these factors will affect its outcome and might subject your patient’s life to danger.
Information about the patient’s age and current health condition will help you assess the case before starting any medical examinations or writing a care plan. Caregivers and family members can help if your patient is unable to provide accurate data.
A full medical history is one of the most crucial sources of data that you should study before working on your nursing care plan. If medical sources are not available, a preliminary physical examination can help explain the patient’s health condition. A nurse should examine the patient’s body for ulcers, wounds, trauma, and other signs that might show skin integrity before writing a care plan.
With the right information, a nurse can come up with a comprehensive nursing care plan that helps the patient overcome the current health problem; deal with risks of skin integrity, and help family members or caregivers avoid such situations in the future.
What are the Risks of Skin Integrity?
If a tissue is damaged, exposed, or dehydrated, it becomes unable to recover and restore its original state. This puts the patient in great health risk and will be subject to various serious infections that can be life-threatening. Here are some risk factors that indicate that your patient is suffering from an impaired tissue integrity problem:
- A patient is extremely overweight or unable to move because of paralysis. Immobility and being bedridden are two factors that subject tissues to ulcers and wounds. The skin is unable to breathe, and trapped moisture and heat help the bacteria grow and infect the open wounds.
- People who suffer from spinal cord injuries and spend most of their time in the bed or wheelchairs. Extra pressure can cause ulcers that become difficult to deal with, especially if the patient doesn’t feel the pain.
- Inadequate nutrition due to sickness or age is another risk factor. Our bodies need water, vitamins, and minerals to stay in good condition and the lack of those can affect tissues. They become weak or chaffed and subject to ulcers and injuries.
- Chemicals like dyes, detergents, and soaps are risk factors. People who use or work with these chemicals are subject to skin integrity.
- Hyperthermia and hypothermia affect skin’s condition. Unless they’re dealt with promptly, they can result in serious problems.
- History of chemotherapy or radiation therapy means that the skin has been previously jeopardized and special care is needed to avoid any further problems.
- Lack of elasticity and vascular problems due to age makes the skin more vulnerable.
An overall assessment is needed to help a nurse understand the current condition of the skin. This facilitates the creation of a comprehensive care plan for impaired skin integrity to make sure that the patient is taken care of.
What are the Goals of a Nursing Care Plan for Impaired Tissue Integrity?
The main goal of your nursing care plan is to keep a patient’s skin intact and in good condition. There should be no dry, ulcers, wounds or red spots. Ultimately, the plan should result in:
- Decrease in size of wounds until they are fully healed.
- Absence of skin breakdowns and impairment.
- Decrease and absence of irritation, itching or redness.
- An altered sensation at the site of impaired tissue, if possible.
The look of normal skin differs from one individual to another. But generally speaking, skin should be free from wounds, cuts, ulcers, and other injuries. It should be warm and soft to touch, with no dry scales. It should feel somehow moist and should have fast capillary refill in about 6 seconds or less.
Exposed skin that shows any bony prominences should be restored to normal. These areas are at high risk because the skin is taut. If skin has lost its elasticity for any reason, then a comprehensive nursing care plan for impaired skin integrity is needed as soon as possible to guarantee that no further damage is going to happen.
Initial and long-term care should be both administered to make sure that skin’s condition isn’t changing to a worse state. Observation and assessment should be done every 24 hours upon admission to make sure that current risks are adequately dealt with. After a patient is dismissed, a follow up is recommended every one to four weeks to handle any unexpected changes.
Working on Your Nursing Care Plan
If you’re currently studying nursing, then you understand the importance of nursing interventions for impaired skin integrity. Such practices can save the patient’s health and improve the life quality of the patient and his family. Here are some steps that can help you while writing a nursing care plan:
- Examine external tissues for signs of trauma like itching, swelling, redness.
- Determine the type of impairment. This could be a chronic wound, an ulcer or a burn. This helps you decide on the proper method of intervention later on.
- Find any signs of scratching which can worsen the tissue’s condition.
- Measuring body temperature to find out if there’s an infection.
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