- Provide systematic skin inspection at least daily based upon characteristics listed in Nursing Assessments.
- Implement prevention protocols based on the potential for the following:
- Stripping/Shearing Injury—proper turning, positioning techniques, careful selection and removal of adhesives, use of alternatives to tape.
- Perineal Skin Compromise—cleanse and protect tissue at frequent intervals, gently cleanse skin, frequent use of a moisturizer or barrier is recommended with incontinence, appropriate use of incontinence containment products (e.g., fecal collectors, external urinary collection pouches, external urinary catheters) is recommended.
- Arterial Ulcer—consult with physician regarding ischemia and planned treatment, protect extremity from trauma, cleanse, moisturize, and protect intact skin, avoid foot soaks.
- Neuropathic Ulcer—consult with physician if ischemia exists, protect from injury with orthotics or other appropriate footwear, cleanse, moisturize, and protect intact skin, avoid foot soaks.
- Pressure Ulcer—proper positioning, turning, patient support surface and/or wheelchair seat are essential, cleanse, moisturize, and protect intact skin, avoid massage of bony prominences, orthotic devices.
- Venous Ulcer—compression therapy, leg elevation, exercise (e.g., walking), weight management as needed, cleanse, moisturize, and protect intact skin.
- Provide adequate nutritional intake and hydration. Education plans should include compliance with care, medications, and preventive approaches (e.g., smoking cessation, weight control).
- Provide education to patient, family, and caregiver.
- Document assessments and interventions.
- Reassess at regular intervals per agency protocol.
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