Nursing Care Plan

Return to Care Plan Listing
 





 

Medical Diagnoses: Risk for impaired skin integrity, Immobility and Mechanical factors (shearing, friction)

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

     

Pt demonstrated discomfort through grimacing and the tightening of her muscles during a BM clean up.

     

     

Objective:

     

Pt is physically immobile and unable to get out of bed.

     

An area on the pt’s buttocks was reddened and warm to touch.

     

Pt is incontinent of her bowels, which leads to moisture on her skin. 


Problem:

     

Risk for impaired skin integrity

    

    

    

    

    

    

    

Long Term:

Pt will verbalize the measures needed to promote good skin integrity by discharge.



 *Educate pt on the importance of proper dieting and food intake.

     

Rationale:

 “… Nutrition is fundamental to normal cellular integrity and tissue repair.” (Potter and Perry, 2008, p. 1310)

     

*Educate the pt on the importance of keeping the skin clean and dry.

     

Rationale:

“Moisture softens the skin and causes a break in the skin integrity.”

(Potter & Perry, 2009, p. 1302)

     

     

     

     

     

    

    

I

Unable to evaluate goal due to pt’s confusion. Hypothetically, once the patient was oriented, she would be taught the needed measures to promote good skin integrity and she would verbalize her understanding.

Unable to evaluate interventions due to pt’s confusion. Hypothetically, once the pt was oriented, she would be taught the appropriate interventions needed to prevent skin breakdown and promote good skin integrity. 

R/T

Immobility

     

Mechanical factors (shearing, friction)

     

Moisture

    

    

    

    

    

    

Short Term:

Pt will not develop any further skin breakdown during her stay at the facility.

*Reposition the pt at least once every two hours.

     

Rationale:

“Positioning interventions reduce pressure and shearing force to the skin.” (Potter & Perry, 2009, p. 1305)

     

*Keep the skin clean and dry

     

Rationale:

“Moisture softens the skin and causes a break in the skin integrity.”

(Potter & Perry, 2009, p. 1302)

     

*Monitor skin condition at least once a day for color or texture changes, dermatological conditions, or lesions.”

     

Rationale: “Systematic inspection can identify impending problems early.” (Ackley & Ladwig, 2008, p. 754)

     

    

    

    

    

I

Goal met. Pt’s skin has no signs of worsening or advanced impairment. Pt’s skin integrity has not been further compromised.


Continue interventions as listed. Reposition the pt at least once every two hours. Continue to keep the pt’s skin clean and dry. Continue to monitor the skin for any signs of change or breakdown.

AEB

    

Grimace during incontinence cleaning

     

Reddened area on pt’s buttocks.

    

    


 

1,800 Cardiovascular review flash cards, download now and ace your exams

  

    

*I = Implementation.  Check those interventions/actions/orders that were implemented.

     

References

 

Ackley, B.J., & Ladwig, G.B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed.). St. Louis: Mosby Elsevier.           

Potter, P.A., & Perry, A.G.(2009). Fundamentals of nursing (7th ed). St. Louis: Mosby Elsevier.



Return to Table of Contents