Nursing Care Plan for Those at Risk for Impaired Skin Integrity
Regular assessment of the skin is critical for those at risk for impaired skin integrity. Pressure areas must be treated with white wool or sheepskin and examined with a long-handled metal spatula to detect any signs of redness, heat, or swelling. Based on assessment findings, the care plan is developed. It may include wound care, dressing changes, and pressure relief. Prevention of injury and other factors may also be included in the care plan.
Performing a head-to-toe assessment
Performing a head-to-toen assessment is important in detecting changes in skin integrity and identifying any conditions that can affect skin health. Patients who have difficulty moving should be placed on appropriate pressure-relieving surfaces and cushioning devices. For patients who have a history of pressure ulcers, it is crucial to perform a full head-to-toe assessment.
Impaired skin integrity can be caused by a number of conditions and can be prevented or reduced by therapeutic interventions. One of the most important prevention strategies is avoiding patients from elevating the head of the bed. This practice can shift the body’s weight downward and onto the sacrum. Patients should be transferred from bed to chair at least every 15 minutes and should change position every hour if they are confined to a wheelchair.
Impaired skin integrity is the result of a breakdown of the skin barrier. The National Council Licensure Examination defines impaired skin integrity as the disruption of the barrier function of the skin, allowing harmful external factors to reach the body tissues. Impaired skin integrity can result from various causes, including burns in different stages, pressure ulcers, dermatitis, and eczema. Impaired skin can also result from a lack of moisture in the skin. Impaired skin is more likely to occur in older adults.
Preventing skin breakdown
Identifying the cause of impaired skin integrity and providing appropriate treatment requires an assessment. Impaired skin may be damaged by external factors, such as injury or exposure to toxic substances. While some tissues may repair themselves, other tissues do not. In the case of impaired skin integrity, a thorough assessment is necessary to identify the type of tissue damage and possible nursing interventions. A thorough assessment will determine the cause of the impaired skin, and the nursing care plan will be based on those findings.
In nursing, prevention is key. Nursing care plans should include the prevention of skin breakdown as well as identifying and assessing risk factors. In this way, nurses can foster positive outcomes for their patients. There are four primary types of nursing diagnosis: problem-focused, risk-based, health promotion-based, and syndrome-based. The latter category includes nursing diagnoses that involve specific risk factors that may impede skin integrity. Examples include ineffective breathing patterns, such as those associated with smoking, pneumonia, and chronic pain syndrome.
Treating necrotizing fasciitis
Although rarely seen in children, necrotizing fasciitis is a potentially fatal condition if not treated early. The infection is difficult to distinguish from other forms of superficial skin infection, which can lead to high morbidity and mortality. Its causes are unknown, but treatment should be aggressive. This condition can be focal or diffuse, and it can present in different forms.
In some cases, silver compounds may be applied to affected tissues or used as a wound dressing to prevent further infection. Alternatively, the silver compounds may be used to promote proper hand hygiene and skin care. These treatments are beneficial in preserving the integrity of the skin. Nursing care plans should be tailored to each patient’s needs. These recommendations are not meant as a replacement for professional diagnosis.
As part of the patient’s nursing care plan, a dietician should help them meet their nutritional and hydration needs. Education about proper skin care is essential to enhance the patient’s self-efficacy and prevent complications. A wound, ostomy, and continence nurse is an excellent resource for patient education and prevention. If necrotizing fasciitis is diagnosed during a hospital stay, an appropriate nursing care plan can be developed to address the condition and minimize the risk of complications.
Treatment of Kawasaki disease
IVIG (intravenous immunoglobulin) is the mainstay of treatment for children with Kawasaki disease. This treatment is effective in children with recurrent fever despite IVIG therapy. Patients can also benefit from the use of TNF-a antagonists and abciximab. The risk of coronary artery abnormalities associated with Kawasaki disease is as low as two to four percent.
Initial treatment for Kawasaki disease focuses on reducing fever and inflammation and preventing further heart damage. It may include the use of intravenous immunoglobulin and aspirin to reduce inflammation of the vessels. Aspirin is often used as an over-the-counter anti-inflammatory in children, but this treatment may lead to Reye syndrome, a potentially fatal condition affecting the liver and brain. Therefore, it is necessary to discuss the risks and benefits of aspirin before prescribing it to your child.
A thorough clinical examination and detailed history will confirm a diagnosis of Kawasaki disease. The typical symptoms are fever that lasts for a minimum of two weeks. Other signs include swollen lymph nodes, inflammation of the mucous membranes, and dry cracked lips. The body’s immune system may also be compromised, which makes treatment of Kawasaki disease important. If the symptoms persist, a patient should seek immediate medical care.
