What should I consider when creating a skin integrity care plan?
Start with a comprehensive risk assessment and skin inspection. Once the risk and skin assessments are complete, all identified risk factors or skin concerns should be included in the care plan.
Next, ensure the risk and skin concerns identified have correlating interventions to modify, stabilize and eliminate the identified risk factors. When considering which to select, it’s important to understand the root cause of risk factors to help determine the appropriate intervention.
However, given the multitude of possible interventions, this can seem overwhelming. One solution is to develop a suggestion sheet of potential interventions for common risk factors. You can use this sheet as a resource for selecting interventions.
Some risk factors, such as urinary incontinence or a nutritional deficit, will require their own care plan problem. In this case, list the risk factor under skin integrity. Then, under interventions, state “See elimination problem” or “See nutritional problem.” This will eliminate having conflicting interventions listed.
Ensure that goals selected are measurable and realistic. For example, don’t state that an arterial wound with no circulation will heal in three months. Instead, your goal may be that the arterial wound will remain stable.
The care-planning process can become less intimidating if you break it into steps: First, gather information with a comprehensive risk tool. Then, develop the interventions utilizing a suggestion sheet of potential interventions to consider. Finally, develop goals that are measurable and realistic.
It’s imperative to ensure all interventions to be implemented by the nursing assistant are clearly communicated and documented on the nursing assistant assignment sheet.
From the August 2019 Issue of McKnight's Long-Term Care News
