Avoid massaging around the site of skin impairment and over bony prominences. Teach client to use pillows, foam wedges, and pressure-reducing devices to prevent pressure injury. Rubbing the skin with a towel can irritate the skin and exacerbate the itch-scratch cycle. Do not position client on site of skin impairment.
Identify a plan for debridement if necrotic tissue eschar or slough is present and if compatible with overall patient management goals. Prior assessment of wound etiology is critical for proper identification of nursing interventions van Rijswijk, Nurse will teach the patient techniques to keep skin clean and dry.
After bathing or showering the skin must be thoroughly dried. In areas of the body where the skin is thin and prone to breakdown, one should apple a protective dressing. Classify superficial pressure ulcers in the following manner: 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.
Irritation from sweat or other bodily fluids. Refer to a urologist or gastroenterologist for incontinence assessment Doughty, ; Wound, Ostomy, and Continence Nurses Society,; Fantl et al, Care Plans are often developed in different formats. Pressure mapping uses special mats to create a map of pressure distribution, pinpointing the highest areas of pressure.
If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. To promote compliance to medication and preventing future injury.
Premedicate for dressing changes as necessary. Systematic inspection can identify impending problems early Bryant, A validated risk-assessment tool such as the Norton or Braden scale should be used to identify clients at risk for immobility-related skin breakdown Panel for the Prediction and Prevention of Pressure Ulcers in Adults, Avoid dragging or pulling skin across surfaces when moving from a wheelchair to a bed transferring.
Nursing Assessment Assessment is required in order to recognize possible problems that may have lead to Impaired Tissue Integrity as well as identify any episode that may transpire during nursing care.
Patient maintains optimal skin integrity within limits of the disease, as evidenced by intact skin. Prior assessment of wound etiology is critical for proper identification of nursing interventions. The patient may begin using over-the-counter hydrocortisone preparations. The most common cause of pressure wounds and skin integrity issues is constant pressure to the skin as it gets squeezed against a surface such as a bed or wheelchair.
Pay special attention to high-risk areas such as bony prominences, skinfolds, the sacrum, and heels. Healing does not transpire in the appearance of necrotic tissue. Teach client to use a topical treatment that is matched to the client, wound, and setting.
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. Administer antibiotics as ordered.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. 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. This care plan is listed to give an example of how a Nurse (LPN or RN) may plan to treat a patient with those conditions.
Nursing Care Plan for Impaired Skin Integrity | Diagnosis & Risk for Pressure Ulcers, Risk for Skin Breakdown, Altered Skin Integrity. In this paper, I will explain teaching plan for diabetes patient with regular insulin injection including with the purpose of plan, outcomes, behavioral objectives, and teaching method.
Diabetes is a common disease, which can be a serious life-long illness caused by high level of glucose in the blood. The Indiana Pressure Ulcer Initiative is a health care initiative of the Indiana State Department of Health and the University of Indianapolis Center for Aging & Community.
Date & Sign. Plan and Outcome [Check those that apply] Target Date: Nursing Interventions [Check those that apply] Date Achieved: The patient will: (_)Maintain.Download