Nursing Care Plan


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Medical Diagnoses: Impaired Skin Integrity, Mechanical Factors and immobilization

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

   

Paitent complains of headache and back pain 6/10 that is constant, aching, and that makes her not want to move about “anymore than she has too”.

   

Objective

Skin is warm, normal in color, except for areas of bruising on upper arms

Stage II ulcer noted on coccyx, 2x3 inches in size, 1 inch in depth, with clear, non-odorous drainage, surrounding skin pink and is intact.

   

Problem

   

Impaired Skin Integrity

   

   

   

   

   


Long Term:

Client will regain integrity of skin surface by the time of discharge.

Monitor the client's continence status, and minimize exposure of skin impairment and other areas of moisture from incontinence, perspiration, or wound drainage. EBN: Moisture from incontinence contributes to pressure ulcer development by macerating the skin (WOCN, 2003).

Do not position the client on site of skin impairment. If consistent with overall client management goals, turn and position the client at least every 2 hours. Transfer the client with care to protect against the adverse effects of external mechanical forces such as pressure, friction, and shear.

EditSelect a topical treatment that will maintain a moist wound-healing environment and that is balanced with the need to absorb exudate. EBN: Choose dressings that provide a moist environment, keep periwound skin dry, and control exudate and eliminate dead space (WOCN, 2003).

   

   


   

R/T

Mechanical Factors and immobilization

   

   

 

  

   

   

   

Short Term:

Client will Editdescribe measures to protect and heal the skin and to care for any skin lesion

Individualize plan according to the client's skin condition, needs, and preferences. EBN: Avoid harsh cleansing agents, hot water, extreme friction or force, or cleansing too frequently (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992; Wound, Ostomy, and Continence Nurses Society WOCN 2003).

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).

EditIf consistent with overall client management goals, teach how to turn and reposition at least every 2 hours. EB: If the goal of care is to keep a client (e.g., terminally ill client) comfortable, turning and repositioning may not be appropriate (Krasner, Rodeheaver & Sibbald, 2001; Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).

   

   

   

   


AEB

Stage II ulcer noted on coccyx, 2x3 inches in size, 1 inch in depth, with clear, non-odorous drainage, surrounding skin pink and is intact.

   

   

   

   

   

   

 

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



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