Request a consult with a registered dietitian
🌼 The client has poor nutritional intake, consuming only 25% of breakfast and 10% of lunch.
🌼 Adequate nutrition is essential for maintaining skin integrity, tissue repair, and immune function.
🌼 Clients with inadequate nutritional intake have an increased risk of developing pressure injuries and delayed wound healing.
🌼 Repeated loose stools can contribute to additional fluid and nutrient losses, further increasing nutritional risk.
🌼 Diabetes can impair tissue healing, making nutritional optimization particularly important for this client.
🌼 A registered dietitian can evaluate caloric, protein, fluid, and micronutrient requirements and recommend an individualized nutritional plan.
🌼 Nutritional assessment also helps identify deficiencies that may contribute to skin breakdown and poor healing.
🌼 A dietitian consultation is therefore appropriate as part of this client's pressure-injury prevention plan.
Provide a support pressure-redistribution surface
🌼 The client's decreased lower-extremity mobility and sensation place them at substantial risk for prolonged pressure over bony prominences.
🌼 Reduced sensation can prevent the client from recognizing discomfort that would normally trigger spontaneous repositioning.
🌼 A pressure-redistribution surface helps distribute the client's body weight across a larger surface area.
🌼 This decreases concentrated pressure over vulnerable areas such as the sacrum, heels, and hips.
🌼 Reducing prolonged pressure supports tissue perfusion and decreases the likelihood of ischemic skin damage.
🌼 Pressure-redistribution surfaces are especially important when clients cannot reposition themselves effectively.
🌼 The surface should be used together with regular repositioning, moisture management, nutritional support, and ongoing skin assessment.
🌼 Providing an appropriate support surface therefore directly addresses this client's high risk for pressure injury.
Perform a skin risk assessment weekly
🌼 A structured skin and pressure-injury risk assessment helps identify factors that increase the likelihood of skin breakdown.
🌼 This client has several risk factors, including impaired mobility, decreased sensation, diabetes, incontinence, diarrhea, and inadequate nutritional intake.
🌼 Risk assessment evaluates factors such as mobility, moisture exposure, nutrition, activity, sensory perception, and friction or shear.
🌼 Identifying these risks allows the nurse to implement individualized preventive interventions before skin breakdown occurs.
🌼 Repeated assessment helps identify changes in the client's condition that could increase or decrease risk.
🌼 Skin inspection should also occur routinely and more frequently than the formal scheduled risk reassessment when clinically indicated.
🌼 Any new redness, nonblanchable erythema, moisture-associated damage, or tissue breakdown requires prompt intervention.
🌼 A scheduled skin risk assessment is therefore an important component of the client's preventive care plan.
Use a moisture barrier ointment after cleaning the client's skin
🌼 The client's urinary and fecal incontinence exposes the skin repeatedly to moisture and irritating substances.
🌼 Loose stool contains digestive enzymes that can rapidly damage the epidermal barrier and contribute to incontinence-associated dermatitis.
🌼 The perineal and surrounding skin should be gently cleaned after episodes of incontinence and dried without excessive friction.
🌼 A moisture barrier ointment creates a protective layer between the skin and urine or feces.
🌼 Protecting the skin from prolonged moisture reduces maceration, irritation, and breakdown.
🌼 Maintaining intact skin is particularly important because diabetes can impair circulation and delay healing after tissue injury occurs.
🌼 Moisture management should be combined with frequent assessment and prompt incontinence care.
🌼 Barrier ointment therefore directly addresses one of this client's major modifiable risk factors for skin breakdown.