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Assessment
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Nursing DX/Clinical Problem
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Client Goals/Desired Outcomes/Objectives
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Nursing Interventions/Actions/Orders and Rationale
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*I
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Evaluation
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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.
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Problem
Impaired tissue integrity stage 3 pressure ulcer
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Long Term:
Client will describe
measures to protect and heal the tissue including wound care by discharge/
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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).
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*
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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.
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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.
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R/T
Skeletal prominence
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Short Term:
Client will
report any altered
sensation or pain at the site of tissue impairment by 1300 on [date].
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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).
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Patient did not report any change in this pain level
of 1 at 1130 to 1330 at site of tissue impairment.
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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.
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