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Jod Title: Nurse Practical Guideline Integumentary

1 Policy:

1.1 Provides an assessment of the integumentary system will be performed on all

patients at the beginning of every shift, q 4 hours and PRN.

2 Procedure:

2.1 Assess the function of the skin, such as protection (intactness), temperature
regulation, (cutaneous blood flow, heat loss, odor) sensation, tactile, thermal,
pain, and excretion and absorption.

2.2 Perform skin care daily and PRN.

2.3 Identify patients at risk for impaired skin integrity and identify the following
complications and appropriate interventions.

2.3.1 Impaired skin integrity

2.3.2 Infection
2.3.3 Impaired tissue perfusion

2.4 Document all pertinent data.

2.5 Identify necessary supplies and equipment for protection and restoration of
skin integrity.

2.6 Perform appropriate wound care as identified by Wound Care Coordinator

and / or MD.

2.7 Position patients q 1-2 hours to prevent pressure.

2.8 Identify the following complications and interventions appropriately and

document plan:

2.8.1 Altered skin integrity

2.8.2 Infection
2.8.3 Altered nutrition
2.8.4 Fluid volume deficit
2.8.5 Impaired physical mobility

© Cassidy Rabong 2010 Prepared by: SN. CaR

2.9 Trach care will be done q 12 hours and PRN, or as ordered.

2.10 Oral care will be done q 2 hours.

2.11 Foley care will be done q 12 hours.

2.12 Passive range of motion (ROM) will be done on immobile patient q 24 hours
and PRN (done by physiotherapist).

2.13 Patient will be bathed and as indicated.

2.14 Back care will be done as ordered in compromised patients or q 2 hours and
PRN in uncompromised patients.

2.15 Operative dressings

2.15.1 The initial post – op dressing may be reinforced but not changed until
the first dressing change is done by the physician on the first post-op day
2.15.2 All opsite dressing changed q 3 days.
2.15.3 Craniotomy dressings will only be changed by the physician.
Reinforcement will be done with notification to the phycisian.

© Cassidy Rabong 2010 Prepared by: SN. CaR