Risk for Impaired Skin/Tissue Integrity
Risk factors may include
Altered and inadequate peripheral circulation, sensation
Presence of edema, tissue pressure
Altered metabolic state
Immobility, traction apparatus
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Identify individual risk factors.
Verbalize understanding of treatment needs.
Participate to level of ability to prevent skin breakdown.
Nursing intervention with rationale:
1. Inspect all skin areas, noting capillary blanching and refill, redness, and swelling. Pay particular attention to back of head, skin under halo frame or vest, and folds where skin continuously touches.
Rationale: Skin is especially prone to breakdown because of changes in peripheral circulation, inability to sense pressure, immobility, and altered temperature regulation.
2. Observe halo and tong insertion sites. Note swelling, redness, and drainage.
Rationale: These sites are prone to inflammation and infection and provide route for pathological microorganisms to enter cranial ,cavity. Note: New style of halo frame does not require screws or pins.
3. Encourage continuation of regular exercise program.
Rationale: Exercise stimulates circulation that enhances cellular nutrition and oxygenation.
4. Elevate lower extremities periodically, if tolerated.
Rationale: Elevation of lower extremities enhances venous return and reduces edema formation.
5. Avoid or limit injection of medication below the level of injury.
Rationale: Areas below the level of injury have reduced circulation and sensation and are at risk for delayed absorption, local reaction, and tissue necrosis.
6. Massage and lubricate skin with bland lotion or oil. Protect pressure points by use of elbow or heel pads, lamb’s wool, foam padding, and egg-crate mattress or cushion. Use skin-hardening agents, such as tincture of benzoin, karaya, or Sween cream.
Rationale: Skin care and massage enhance circulation and protect skin surfaces, thus reducing risk of pressure ulcers. Tetraplegic and paraplegic clients require lifelong protection from decubitus ulcer formation, which can cause extensive tissue necrosis and sepsis.
7. Reposition frequently, whether in bed or in sitting position. Place in prone position periodically.
Rationale: Repositioning improves skin circulation and reduces pressure on bony prominences.
8. Wash and dry skin, especially in high-moisture areas such as perineum. Take care to avoid wetting the lining of brace or halo vest.
Rationale: Clean, dry skin is less prone to excoriation or breakdown.
9. Keep bedclothes dry and free of wrinkles, crumbs, and creases.
Rationale: Preventing excessive moisture and friction reduces skin irritation.
10. Cleanse halo or tong insertion sites routinely and apply antibiotic ointment per protocol.
Rationale: Halo and tong insertion site care helps prevent local infection and reduces risk of cranial infection.