Friday, March 25, 2011

Risk for Impaired Skin Integrity | Nursing Care Plan for Anorexia/Bulimia

Nursing diagnosis: risk for impaired Skin Integrity

Risk factors may include
Altered nutritional and metabolic state, edema
Dehydration, cachectic changes—skeletal prominence

Desired Outcomes/Evaluation Criteria—Client Will
Risk Control
Verbalize understanding of causative factors and absence of itching.
Identify and demonstrate behaviors to maintain soft, supple, intact skin.

Nursing intervention with rationale:
1. Observe for reddened, blanched, and excoriated areas.
Rationale: Indicators of increased risk of breakdown, requiring more intensive treatment.

2. Encourage bathing every other day instead of daily if this is an area of concern.
Rationale: Frequent baths contribute to dryness of the skin.

3. Use skin cream twice a day and after bathing.
Rationale: Lubricates skin and decreases itching.

4. Massage skin gently, especially over bony prominences.
Rationale: Improves circulation to the skin and enhances skin tone.

5. Discuss importance of frequent position changes and need for remaining active.
Rationale: Enhances circulation and perfusion to skin by preventing prolonged pressure on tissues.

6. Emphasize importance of adequate nutrition and fluid intake.
Rationale: Improved nutrition and hydration will improve skin condition.

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