An eye patch or hard, plastic shield for corneal injury. Note presence of excoriations, erosions, fissures, or thickening. Prior assessment of wound etiology is critical for proper identification of nursing interventions van Rijswijk, Cues organized as Subjective or Objective: Over-the-counter moisturizing lotions include Eucerin, Lubriderm, and Nivea.
Encourage a diet that meets nutritional needs. If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below.
Serous exudate from a wound is a normal part of inflammation and must be differentiated from pus or purulent discharge, which is present in infection. Long-term scarring may result in body image disturbances.
Have difficulty managing their health. Fever is a systemic manifestation of inflammation and may indicate the presence of infection. Identify a plan for debridement if necrotic tissue eschar or slough is present and if compatible with overall patient management goals.
We also specialize in pressure wounds and skin integrity issues caused by limited mobility or loss of sensation. This information helps therapists and seating specialists recommend ways to reduce pressure in these locations.
If consistent with overall client management goals, teach how to turn and reposition at least every 2 hours. These findings will give information on extent of injury.
Odor may be a result of presence of infection on the site; it may also be coming from a necrotic tissue. Our integrated care model is centered on treatment for complex conditions, such as those that can lead to problems with skin integrity or bed sores.
Assess changes in body temperature, specifically increased in body temperature. Monitor status of skin around wound. Maintain the head of the bed at the lowest degree of elevation possible.
Patient described two out of three measures to protect his skin from moisture. If ordered, turn and position patient at least every 2 hours, and carefully transfer patient. Change position for at least two minutes every hour if using a wheelchair. To promote compliance to medication and preventing future injury.
Stage III Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia; ulcer appears as a deep crater with or without undermining of adjacent tissue Stage IV Full-thickness skin loss with extensive destruction; tissue necrosis; or damage to musclebone, or supporting structures e.
A firmer, softer, warmer or cooler feeling in the area compared to other parts of the body. Determine whether client is experiencing changes in sensation or pain. Assess site of skin impairment and determine etiology e.
Select a topical treatment that will maintain a moist wound-healing environment and that is balanced with the need to absorb exudate. The patient who scratches the skin in attempts to alleviate extreme itching may open skin lesion and increase risk for infection.
WBC 22, Blood Sugar There is a classification of pressure ulcers that is followed so that universally, caregivers can know what to give in order to prevent worsening conditions.
To prevent pressure injury. Stage III Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia; ulcer appears as a deep crater with or without undermining of adjacent tissue Stage IV Full-thickness skin loss with extensive destruction; tissue necrosis; or damage to musclebone, or supporting structures e.
Teach skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing. For patients with limited mobility, use a risk assessment tool to systematically assess immobility-related risk factors.
Pain is part of the normal inflammatory process. Goal is attainable, patient was taught techniques to keep skin dry Goal is realistic, client is awake, alert, and oriented and ready to learn techniques to protect skin from moisture.
Patient describes measures to protect and heal the tissue, including wound care. Transfer client with care to protect against the adverse effects of external mechanical forces such as pressure, friction, and shear. Nursing Interventions The following are the therapeutic nursing interventions for Impaired Tissue Integrity:Documenting Teaching and the Plan of Care July 19, Purpose: The purpose of this self-learning module is to provide the All patients with impaired skin integrity must have an “Impaired skin integrity” care plan as well as a “Risk for Impaired skin integrity “care plan.
Pressure Ulcers – are lesions caused by the primary barrier of the body against the outside environment – the skin. It is common in bony prominences in the body wherein friction usually occurs.
The reduction of blood flow in the area leads to skin breakdown. Skin Care Teaching ; Skin Care Teaching Patient was instructed on skin care.
Keep the skin clean and dry. Patient was instructed on factors that contributes to poor skin integrity, such as, immobilization, Patient was instructed on measures to protect the skin, such as, keeping the skin clean and dry, ass.
NURSING CARE PLAN on Impaired Skin Integrity Nursing Diagnosis: Delayed wound recovery due to ineffective therapeutic regimen. management and self-care deficit as evidenced by low self-esteem and impaired physical mobility/5(12). Documenting Teaching and the Plan of Care July 19, Purpose: The purpose of this self-learning module is to provide the All patients with impaired skin integrity must have an “Impaired skin integrity” care plan as well as.
Skin Care Teaching Patient was instructed on the importance of skin integrity to prevent future complication: Massage reddened skin gently al least 3 or 4 times daily. Keep the skin clean and dry and after use a protective ointment or spray. Skin Care TeachingDownload