Nursing Interventions and Rationale

Nursing Interventions and Rationale

SMART Goal

To maintain intact skin integrity without complications.

Nursing Interventions and Rationale

– Assess and evaluate the condition of the skin. The skin’s overall condition dictates the nursing interventions specific to the patient (Carlin, 2022). Skin appearance and features differ among individuals; therefore, it is crucial to identify what normal skin means to a patient. Assessment for healthy skin includes skin turgor, touch, capillary refill, presence or absence of abrasions, wounds, rashes, and other impairments. Healthy skin should have a good turgor, capillary refill of fewer than six seconds, and be free from impairment. Skin assessment considers a patient’s age. The elderly are at high risk for skin impairment compared to younger individuals. The elderly’s skin is primarily dry and non-elastic. – Evaluate the patient’s mobility. The patient has a risk for impaired skin integrity related to impaired physical mobility. Impaired physical mobility is the most significant risk factor in skin breakdown; therefore, evaluate the patient’s ability to move (Carlin, 2022). The patient’s strength to move is determined by asking the patient to turn over in bed, move from the bed to a chair close to the bed, walk from one point to another, and shift weight while seated. – Assess the surface where the patient spends most of their time. The patient has impaired physical mobility and is likely to spend most of their day on the same surface. Surfaces to assess include wheelchair cushions, chair cushions, and bed mattresses. Pressure on surfaces should be reduced and evenly distributed to ensure patient comfort and decrease the chances of breakdown (Mitchell, 2022). – Assess the skin for edema to decrease the risk of impaired skin integrity (Carlin, 2022). – Monitor environmental factors such as moisture that cause skin maceration (Mitchell, 2022). –  Assess the patient for conditions that cause immunosuppression, such as HIV/AIDS. Immunosuppressed individuals are at high risk for Dermatological conditions and slow wound healing (Rollan et al., 2022).

 References

Carlin A. S. (2022). Essentials of wound care: assessing and managing impaired skin integrity. Nursing standard (Royal College of Nursing (Great Britain): 1987), 37(10), 69–74. https://doi.org/10.7748/ns.2022.e11964.

Mitchell A. (2022). Skin assessment in adults. British journal of nursing (Mark Allen Publishing), 31(5), 274–278. https://doi.org/10.12968/bjon.2022.31.5.274.

Rollan, M. P., Cabrera, R., & Schwartz, R. A. (2022). Current knowledge of immunosuppression as a risk factor for skin cancer development. Critical reviews in oncology/hematology, 177,103754. https://doi.org/10.1016/j.critrevonc.2022.103754 .

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Purpose of the Assignment

1. Plan evidence-based interventions to assist the client in meeting optimum outcomes.
2. The actions planned are designed to meet the healthcare needs of the client
   

   Nursing Interventions and Rationale

Course Competencies

• Apply knowledge of integumentary disorders for safe, effective nursing care
• Explain components of multidimensional nursing care for clients with musculoskeletal disorders
• Select appropriate nursing interventions for clients experiencing alterations in mobility

Instructions

Develop a client-centered SMART goal and 6 individualized nursing interventions with rationale (using the template on page 2 of this document) for a client with the following nursing diagnosis on the care plan:

• Risk for impaired skin integrity related to mechanical factors and impaired physical mobility.