[FEET AND LEGS] [INCONTINENCE] [DESICCATED SKIN]

SKIN CARE-FEET AND LEGS
NURSING DIAGNOSES: Impairment of skin integrity related to dry, flaky and/or hypertrophic skin of feet and legs.

OUTCOME STANDARDS: Patient attains/maintains intact, pliable skin on feet and legs. Prevention of callus build-up, cracking and/or ulceration on feet and legs.

PROCESS STANDARDS:

• Assessment
  • Present skin condition
  • Nutrition and hydration status
  • History of vascular disease
  • Treatment of vascular disease

• Intervention
  • Inspect feet and legs daily
  • Assure adequate nutrition and fluid intake
  • Monitor medical management of vascular disease

• Provide Foot Care
  • Keep feet and legs clean and well lubricated.
  • Do not soak feet. After bathing, dry thoroughly, especially between toes.
  • Monitor medical management of vascular disease.
  • After bathing, apply a thin coat of lubricating cream. (i.e. Lantiseptic® Therapeutic Cream or Lantiseptic® Skin Protectant) and gently massage between toes. Reapply cream within twelve (12) hours.
  • Document skin condition and treatment at least daily.
  • If areas ulceration occur notify MD within 8 hours to assure appropriate wound care.

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INCONTINENT PATIENTS
NURSING DIAGNOSES: Impairment of skin integrity related to incontinence, potential or actual.

OUTCOME STANDARDS: Prevent skin damage caused by continued exposure to moisture and irritants. Patient attains/maintains intact skin.

PROCESS STANDARDS:

• Assessment
  • Present skin condition
  • Incontinence pattern (urine, fecal, both)
  • Incontinence management protocol
  • Allergies

• Intervention
  • Gently cleanse skin with body wash (i.e. Lantiseptic® All Body Wash) after each incontinent episode (NOTE: the use of harsh soaps can alter skin pH, permitting bacterial growth or cause dryness leading to cracking).
    
    
  • Apply skin protectant (i.e. Lantiseptic® Skin Protectant) to perineal/ peri-anal area after each cleansing. Emollients are designed to condition the skin and provide a barrier against the irritants in cases of incontinence.
    
    
  • Assure adequate fluid intake. (NOTE: withholding fluids is not appropriate management for incontinence and may result in urinary tract infection).
    
    
  • If impairment of skin occurs, continue preventative measures to promote healing and provide protection.
    
    
  • Check incontinent patient's skin every 2hrs for soiling; reapply skin protectant as needed. (NOTE: If maculopapular rash consistent with Candidiasis occurs, antifungal preparations are indicated.)
    
    

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MANAGEMENT OF DESICCATED SKIN
NURSING DIAGNOSES: Impairment of skin integrity related to desiccation/dry skin.

NOTE: Fissuring and cracking of the skin may lead to deep ulceration, especially the extremities (hands, feet, legs). Decreased skin hydration reduces pliability; cracks may occur in the epidermis. Topical moisturizers facilitate skin hydration and reduce the incidence of breaks in the skin.

OUTCOME STANDARDS:

• To attain soft pliable skin.
• To prevent ulceration when broken skin occurs.

PROCESS STANDARDS:

• Assessment
  • Examine the skin daily for areas of dry, flaky or scaling skin.

• Intervention
  • Educate the patient/family regarding the importance of maintaining soft, pliable skin.
    
    
  • Gently massage all areas of dry, cracked or broken skin at least every twelve hours (q12h) with moisturizers (i.e., Lantiseptic Therapeutic Cream or Lantiseptic Skin Protectant).
    
    
  • If areas of broken skin are on the hands, apply moisturizer after each hand washing. Every eight hours (q8h) if bedridden patient.
    
    
  • If broken skin occurs on the feet, apply moisturizer every eight to twelve hours (q8-12h). White socks are indicated. If the patient has insensate feet, shoes should be worn at all times to prevent further trauma damage. Orthotics or special shoes may be necessary to avoid pressure if foot deformities are present.
    
    
  • Apply moisturizers every twelve hours (q12h) to areas of dry skin in the lower extremities, under compression, for patients who have venous hypertension to prevent ulceration.
    
    
  • Interventions should be monitored and documented daily.

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Care Plan prepared by
Norma Mash, RN, BSN, CETN
Kennesaw, Georgia