Nursing Care Plan Preterm Infant | Risk for Impaired Skin Integrity

Nursing diagnosis: Risk for impaired skin integrity may be related tothin skin, fragile capillaries near the skin surface, absence of subcutaneous fat over bony prominences, inability to change positions to relieve pressure points, use of restraints (protecting invasive lines/tubes), alterations in nutritional state.

Desired Outcomes: Maintain intact skin. Be free of dermal injury.

Nursing intervention with rationale:
1. Inspect skin, noting areas of redness or pressure.
Rationale: Identifies areas of potential dermal breakdown, which can result in sepsis.

2. Provide mouth care using saline or glycerin swabs. Apply petroleum jelly to lips.
Rationale: Helps prevent drying and cracking of lips associated with absence of oral intake or the drying effects of oxygen therapy.

3. Avoid application of harsh topical agents; carefully wash off povidone-iodine solutions after procedures.
Rationale: Helps prevent skin breakdown and loss of protective epidermal barrier.


4. Provide range-of-motion exercises, routine position changes, and fleece or flotation pad.
Rationale: Helps prevent possible necrosis related to edema of dermis or lack of subcutaneous fat over bony prominences.

5. Minimize use of tape to secure tubes, electrodes, urine bags, IV lines, and so forth.
Rationale: Removal of tape may accidentally remove epidermal layer, because cohesion is stronger between tape and stratum corneum than between dermis and epidermis.

6. Bathe infant using sterile water and mild soap. Wash only grossly soiled body parts. Minimize manipulation of infant’s skin.
Rationale: After 4 days, skin develops some bactericidal properties because of acid pH. Frequent bathing using alkaline soaps or moisturizers may raise skin pH, compromising normal flora and natural defense mechanisms that protect against invading pathogens.

7. Change electrodes only when necessary.
Rationale: Frequent changing may contribute to skin irritation/dermal injury.

8. Apply antibiotic ointment to nares, mouth, and lips if they are cracked or irritated.
Rationale: Promotes healing of lesions associated with administration of oxygen; reduces risk of infection.