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NCP Impaired Skin Integrity — Heart Failure (CHF)

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NURSING DIAGNOSIS: Skin Integrity, risk for impaired


Risk factors may include

  • Prolonged bedrest
  • Edema, decreased tissue perfusion

Possibly evidenced by

  • [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes
Tissue Perfusion: Peripheral (NOC)

  • Maintain skin integrity.
  • Demonstrate behaviors/techniques to prevent skin breakdown.

Nursing Interventions & Rationale

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.
 Source:
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