NDP 20o
July 2018
Risk for Impaired Skin Integrity
Page1
NAME __________________________________________________
Risk for Impaired Skin Integrity
(Pressure Sores/Ulcers/Bed Sores/Decubitus)
Date Problem Goal/Outcome Interventions Date Evaluation NOTES
Related To:
□ Current decubitus
____________
(location & stage)
□ Immobility
□ Incontinence
□ vascular
insufficiency
□ Altered sensation
□ Other
AEB:
□ break in skin
□ wheel chair/bed
bound
□ Diagnosis of
Diabetes
□ Incontinent of
urine/bowel
□ Hx of radiation
□ Overweight
□ Poor circulation
□ Other
1. Skin intact
NURSING
1. Assess skin _______
(freq)
2. Assess awareness of
sensation of pressure
3. Assess ability to
move
4. Assess bowel/bladder
control
5. Post turning schedule
as appropriate
6. Encourage use of
pressure relieving
devices as
appropriate
7. Keep skin clean, dry
and moisturize skin
as appropriate
8. Encourage adequate
nutrition and
hydration
DELEGATE
1. Monitor skin daily
2. Assist with position
changing as directed
3. Keep skin clean, dry
and moisturize skin
as directed
4. Use pressure
relieving devises as
directed
(Address all items
circled in “goal/
outcome” column. If
goal not met, revise
plan)
