Risk factors may include
- Prolonged bedrest
- Edema, decreased tissue perfusion
Possibly evidenced by
- [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
Tissue Perfusion: Peripheral (NOC)
- Maintain skin integrity.
- Demonstrate behaviors/techniques to prevent skin breakdown.
Nursing Interventions & Rationale
|Inspect skin, noting skeletal prominences, presence of edema, areas of altered circulation/pigmentation, or obesity/emaciation.||Skin is at risk because of impaired peripheral circulation, physical immobility, and alterations in nutritional status.|
|Provide gentle massage around reddened or blanched areas.||Improves blood flow, minimizing tissue hypoxia. Note:Direct massage of compromised area may cause tissue injury.|
|Encourage frequent position changes in bed/chair, assist with active/passive range of motion (ROM) exercises.||Reduces pressure on tissues, improving circulation and reducing time any one area is deprived of full blood flow.|
|Provide frequent skin care; minimize contact with moisture/excretions.||Excessive dryness or moisture damages skin and hastens breakdown.|
|Check fit of shoes/slippers and change as needed.||Dependent edema may cause shoes to fit poorly, increasing risk of pressure and skin breakdown on feet.|
|Avoid intramuscular route for medication.|| Interstitial edema and impaired circulation impede drug absorption and predispose to tissue breakdown/
development of infection.
|Provide alternating pressure/egg-crate mattress, sheep skin elbow/heel protectors.||Reduces pressure to skin, may improve circulation.|