Ncp- Impaired Skin Integrity

Javier, Jomar A.

BSN121/ Group 83

Far Eastern University Institute of Nursing 

Nursing Diagnosis/

Nursing Care Plan Goal & Objectives Objectives Nursing Intervention Intervention

  Analysis

Rationale

Evaluation

Cues Impaired Skin Integrity r/ t pressure ulcer secondary to prolonged immobility and unrelieved pressure Subjective : y The relative mentioned nagsusugat yung may pwetan nya. Siguro dahil matagal na siyang nakahiga. Objective: y Presence of grade 1 pressure ulcer on the lumbar area. y Disruption of skin surface (epidermis)

Skin is the primary defense of the body; it protects the body against infections and diseases brought about by the invasion of microbes in the body. A normal skin is moist and intact; dryness of the skin is more prone to friction that may result to impairment of  the skin integrity as compared with a moist skin. Pressure on soft tissues between bony prominences  Compresses capillaries &

y

Short Term: After 6-8 hrs of  nursing interventions of  nursing interventions, the client will: 

Have reduced risk of  further impairment of  skin integrity Patients  caregivers will demonstrate understanding & skill in care of  wound

Term: After 3-4 days of  nursing interventions, the client will:

Independent:

Assess between folds of  skin, remove anti embolic stockings or devices & use a mirror to see the heels. Also assess under oxygen tubing especially on t he ears & the cheek, beneath splints and under medical devices.  Note objective data of  pressure ulcer (stage, length, width, depth, wound bed appearance, drainage & condition of periulcer tissue) 

 Pressure

ulcers under medical devices are commonly overlooked.

y

 Reassessment

of  ulcer is completed each time dressing are changed or sooner if ulcer shows manifestations of  deterioration. Analyses of the trends in healing are important step in assessment.

Long

y

Experience

healing

of 

y

Increase the

frequency of turning (turning q2). Position the client to stay off the ulcer. If 

y

y

To

disperse pressure over time or decreasing the

Responses to interventions/ teaching plans and actions performed. Attainment/pro gress toward desired outcome(s) Modifications of plan of care.

occludes blood flow  Pressure not relieved  Microthrombi formation  + occlusion in capillaries & blood flow  Formation of  blister  Rupture of  blister  + open wound

y

ulcer/regain skin integrity (reduce size of  ulcer) Reduce risk for infection y

y

y

there is no turning surface without a pressure ulcer, use a pressure redistribution bed & continue turning the client Elevate heels off the bed by using pillows or heel elevation botts. of bed @ the lowest elevation, if client must have the head elevated to prevent aspiration, reposition to 30 degree lateral position. Use seat cushions & assess sacral ulcers daily. Follow body substance isolation precautions; use clean gloves & clean dressing for wound care. Practicing proper hand washing before & after wound care.

tissue load

y

Heel

covers do not relieve pressure, but they can reduce friction.

y

To

y

To

y

To

y

To

Maintain head

prevent further occurrence of  pressure ulcer.

reduce risk of  infection

Dependent/Collaborative: Ensure adequate dietary intake. Review dieticians recommendations. Prevent the ulcer 



prevent malnutrition & delayed healing prevent

from being exposed to urine & feces. Use indwelling catheters, bowel containment systems, & topical creams or dressings.  Supplement the diet with vitamins & minerals. Vitamins C and zinc are commonly prescribed. oral supplementations, tubefeedings or hyperalimentation to achieve positive nitrogen balance. Remove devitalized  tissue from the wound bed, except in the avascular tissue or on the heels. Began by cleansing the ulcer bed with normal saline, then use appropriate technique for debridement. Once the ulcer is free of devitalized tissue, apply dressing the keep the wound bed moist & the surrounding skin dry. Do not use occlusive dressings on ulcer. 

Provide

contamination/spr ead of infection

y

y

y

To

promote wound healing on clients who do not have adequate calories. Pressure ulcers cannot heal in clients with severe malnutrition.

To

promote faster & reduce infection healing