The skin consists of several layers, from the outermost to innermost, and skin from one part of the body to another part very different. The area of the face and neck skin is much different from the thickness of the skin in the palm of the hands and feet. The skin receives a stimulus of pain, touch and temperature changes. The skin consists of an outer layer called the epidermis and the inner layer or dermis.
Impaired Skin Integrity common due to several factors, such as an allergy to a certain temperature (climatic factors), living environment that make the skin more sensitive, a lifestyle that is not clean and many more.
Nursing Intervention in Patients with Impaired Skin Integrity
1. Inspect the lesion every day and monitor for signs of infection.
R /: To know and identify the damage to the skin, to make appropriate interventions.
2. Reposition the patient every 2-4 hours and encourage patient to use light clothing and soft looms.
R /: Pressure from clothes, leaving the wound open to air increases the healing process and reduce the risk of infection.
3. Keep looms.
R /: To prevent infection.
4. Use gloves when taking care of the lesion.
R /: To avoid contamination.
5. Involve patient families in providing relief to the patient.
R /: To facilitate the intervention and help increase self-acceptance and dissemination.
6. Collaboration with the medical team for drug delivery.
R /: To prevent further infections.
7. Find the cause itching.
R /: Helps identify the appropriate actions to provide comfort.
8. Record the results of observations in detail.
R /: An accurate description of the skin eruption is required for diagnosis and treatment.
9. Anticipation allergic reactions (get the drug history).
R/ : Rash thorough especially with sudden onset may indicate an allergic reaction to the drug.
10. Maintain humidity (+/- 60%), use a humidifier.
R /: Humidity is low, the skin will lose water.
11. Maintain a cool environment.
R /: Coolness reduce itching.
12. Wash bed linen and clothing with mild soap.
R /: harsh soaps can cause irritation.
13. Encourage to keep nails trimmed always (short).
R /: Reducing the skin damage caused by scratching.
14. Advise patients to avoid use of ointments / lotions purchased without a doctor prescription.
R /: Problems patients can be caused by irritation / sensitive because the treatment itself.
15. Collaboration with the medical team to topical therapy.
R /: Helps relieve symptoms.
16. Monitor the patient's self-image disorder (avoiding eye contact).
R /: Impaired self-image will accompany each disease / circumstances apparent to the client, the impression people against themselves, affect the self-concept.
17. Allow the feelings disclosure.
R /: Patients need to be heard and understood experience.
18. Support efforts to improve the patient's self-image, such as makeup, straightening.
R /: Helps improve self-acceptance and dissemination.
19. Encouraging socializing with others.
R /: Helps improve self-acceptance and dissemination.
20.Observasi vital signs.
R /: Pathogens circulating stimulates the hypothalamus to increase the body temperature.
21. Wash hands before and after the action.
R /: Prevent cross-infection of the wound environment, into the wound.
22. Perform wound care with aseptic and antiseptic techniques.
R /: Preventing the invasion of germs and bacteria contamination.
23. Instruct the patient to spend a portion provided especially high in protein and vitamin C.
R / Nutrition can enhance the immune system and replace damaged tissue and speed up the healing process.
24. Keep the patient's personal hygiene.
R /: Something dirty is a good medium for germs.
25. Collaboration with the medical team in determining antibiotics and examination of leukocytes and erythrocyte sedimentation rate
R /: Increased leukocyte and erythrocyte sedimentation rate is an indication of infection.
- Proper infection control.
- Maintain skin hydration.
- Perform non-pharmacological measures for treatment of pain and pruritus.
- Maintaining nutritional status.
- Improve personal hygiene and home environment.
- Train families established therapeutic program.