Nursing Care Plan

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Medical Diagnoses: Impaired tissue integrity stage 3 pressure ulcer, Skeletal prominence

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

Patient states that he has a skin wound on coccyx area. Says that pain level is of a 1 as off 1330. Also states that he recieves wound care twice a day and thinks wound would hurt without pain medication.

   

   

   

Objective

Upon observing chart, I noticed a picture document of the Stage 3 pressure ulcer on EB’s coccxy area which a a skeletal prominence.  The size was 6cm by 5 cm and showed tunneling in the picture.



Problem

Impaired tissue integrity stage 3 pressure ulcer

   

Long Term:

Client will describe measures to protect and heal the tissue including wound care by discharge/

Teach the client why a topical treatment has been selected. EBN: The type of dressing needed may change over time as the wound heals and/or deteriorates (WOCN, 2003).

*


Upon evaluation patient was able to restate part of the treatment plan includes using an oinment. Patient is making progress toward goal but needs verbalize complete treatment.

Taught patient about wond care.  Teaching included that he is using a wet to dry packing in order to take off all dead skin.  As wound gets better different bandages may be used.  Wound care happens twice daily which includes a Dakin’s solution to help clean and Xenaderm which is the topical medication in order to promote healing.

R/T

Skeletal prominence

   

   

   

   

Short Term:

Client will report any altered sensation or pain at the site of tissue impairment by 1300 on [date].

Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection. Determine whether the client is experiencing changes in sensation or pain. Pay special attention to high-risk areas such as bony prominences, skinfolds, the sacrum, and heels. Systematic inspection can identify impending problems early (Ayello & Braden, 2002).

   

Patient did not report any change in this pain level of 1 at 1130 to 1330 at site of tissue impairment.

Did not the the chance to asses the patient’s wound on coccyx.  Registered nurse assess at 1030 and noted all information in patients chart.

AEB

Stage 3 pressure ulcer on coccyx size 6 cm by 5 cm and tunneling.

 

 

  

   


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