Care Plan for Potential Skin Breakdown

Category / Primary Body System

• Integumentary System

Problem

• Patient is at risk for skin breakdown due to decreased mobility.

Goal

• Patient will not develop any new skin breakdown for 90 days.

Plan/Approach

1. Skin Assessment

   • Assess patient’s skin condition on admission
   • Conduct Norton Assessment on admission, quarterly, and as needed
   • Perform weekly skin assessments by a nurse

2. Therapeutic Interventions

   • Provide PT/OT evaluation and treatment as needed
   • Reposition patient according to facility policy and as needed
   • Use a pressure-relieving mattress on the bed
   • Apply barrier cream per facility protocol

3. Incontinence Management

   • Use incontinence absorbent products as needed

Rationale

1. Skin Assessment

   • Initial and regular skin assessments help identify early signs of skin breakdown, allowing for timely interventions.
   • The Norton Assessment evaluates risk factors for pressure ulcers and guides preventive measures.

2. Therapeutic Interventions

   • PT and OT help improve mobility and reduce the risk of pressure ulcers through targeted exercises and mobility aids.
   • Regular repositioning prevents prolonged pressure on any one area, reducing the risk of skin breakdown.
   • Pressure-relieving mattresses distribute weight more evenly, minimizing pressure points.
   • Barrier creams protect the skin from moisture and friction, key factors in skin breakdown.

3. Incontinence Management

   • Using absorbent products helps keep the skin dry and prevents irritation and breakdown caused by prolonged exposure to moisture.

Actions

1. Skin Assessment

   • Perform a comprehensive skin assessment on admission, documenting any existing issues.
   • Conduct Norton Assessments on admission, quarterly, and as needed, documenting and addressing any changes in risk status.
   • Perform weekly skin assessments and document findings, notifying the healthcare team of any changes.

2. Therapeutic Interventions

   • Schedule PT/OT evaluations and follow through with recommended treatments to improve mobility and strength.
   • Reposition the patient every 2 hours or as per facility policy to prevent pressure ulcers.
   • Ensure the patient has a pressure-relieving mattress, checking for proper function and placement.
   • Apply barrier cream to high-risk areas daily and as needed, following facility protocol.

3. Incontinence Management

   • Provide and change incontinence absorbent products promptly to keep the skin dry.
   • Monitor for and address any signs of incontinence-associated dermatitis.