Potential for Skin Breakdown

Care Plan for Potential for Skin Breakdown

Category / Primary Body System:

Integumentary System

Problem:

I am at potential for skin breakdown due to decreased mobility.

Goal:

I will not have any new skin breakdown for the next 90 days.

Plan/Approach:

1. Skin Assessment:

   • Step-by-Step Approach: Assess patient’s skin condition on admission.
   • Monitoring Strategies: Utilize standardized assessment tools to ensure thorough evaluation.

2. Risk Assessment:

   • Step-by-Step Approach: Conduct a Norton Assessment on admission, quarterly, and as needed.
   • Technological Aids: Use electronic health records to document and track assessments.

3. Physical Therapy/Occupational Therapy:

   • Step-by-Step Approach: Provide PT/OT evaluation and treatment as needed.
   • Engagement in Diversional Activities: Incorporate mobility exercises to improve skin health.

4. Repositioning:

   • Step-by-Step Approach: Reposition patient per house policy and as needed.
   • Monitoring Strategies: Use positioning schedules and support surfaces to prevent pressure ulcers.

5. Pressure Relieving Devices:

   • Step-by-Step Approach: Use a pressure-relieving mattress in bed.
   • Technological Aids: Ensure the mattress is properly maintained and functioning.

6. Skin Protection:

   • Step-by-Step Approach: Apply barrier cream per house protocol.
   • Educational Efforts: Educate patient and family on the importance of skin protection.

7. Weekly Skin Assessment:

   • Step-by-Step Approach: Conduct a weekly skin assessment by a nurse.
   • Monitoring Strategies: Document findings and follow up on any areas of concern.

8. Incontinence Management:

   • Step-by-Step Approach: Provide incontinent absorbent products as needed.
   • Engagement in Diversional Activities: Encourage participation in toileting schedules to reduce incontinence episodes.

Rationale:

• Skin Assessment: Early detection of skin changes allows for timely interventions.
• Risk Assessment: Regular assessments help identify patients at high risk and implement preventive measures.
• PT/OT: Improves mobility and reduces the risk of pressure ulcers.
• Repositioning: Prevents prolonged pressure on vulnerable areas.
• Pressure Relieving Devices: Reduces the risk of pressure injuries.
• Skin Protection: Maintains skin integrity and prevents breakdown.
• Weekly Skin Assessment: Ensures ongoing monitoring and prompt response to changes.
• Incontinence Management: Prevents moisture-related skin damage.

Actions:

1. Skin Assessment:

   • Staff will assess my skin condition on admission.

2. Risk Assessment:

   • Staff will offer a Norton Assessment on admission, quarterly, and as needed.

3. Physical Therapy/Occupational Therapy:

   • Staff will conduct PT/OT evaluation and treatment as needed.

4. Repositioning:

   • Staff will reposition me per house policy and as needed.

5. Pressure Relieving Devices:

   • Staff will put a pressure-relieving mattress in bed.

6. Skin Protection:

   • Staff will provide barrier cream per house protocol.

7. Weekly Skin Assessment:

   • A nurse will conduct a weekly skin assessment.

8. Incontinence Management:

   • Staff will offer incontinent absorbent products as needed.