Javier, Jomar A.

BSN121/ Group 83
Far Eastern University
Institute of Nursing

Nursing Care Plan

Nursing Diagnosis/ Analysis Goal & Objectives Nursing Intervention Rationale Evaluation
Cues
Impaired Skin Skin is the  Responses to
Integrity primary defense Short Term: Independent: interventions/
r/ t pressure ulcer of the body; it After 6-8 hrs of  Assess between folds of Pressure ulcers teaching plans
secondary to protects the nursing skin, remove anti under medical and actions
prolonged immobility body against interventions of embolic stockings or devices are performed.
and unrelieved infections and nursing devices & use a mirror commonly  Attainment/pro
pressure diseases interventions, the to see the heels. Also overlooked. gress toward
brought about client will: assess under oxygen desired
Subjective : by the invasion tubing especially on the outcome(s)
 The relative of microbes in  Have ears & the cheek,  Modifications
mentioned the body. A reduced risk of beneath splints and of plan of care.
“nagsusugat yung normal skin is further under medical devices.
may pwetan nya. moist and impairment of  Note objective data of Reassessment of
Siguro dahil intact; dryness skin integrity pressure ulcer (stage, ulcer is completed
matagal na siyang of the skin is  Patient’s length, width, depth, each time dressing
nakahiga.” more prone to caregivers will wound bed are changed or
friction that may demonstrate appearance, drainage & sooner if ulcer
Objective: result to understanding & condition of periulcer shows
 Presence of grade impairment of skill in care of tissue) manifestations of
1 pressure ulcer the skin wound deterioration.
on the lumbar integrity as Analyses of the
area. compared with trends in healing
 Disruption of skin a moist skin. Long Term: are important step
surface Pressure on soft After 3-4 days of in assessment.
(epidermis) tissues between nursing
bony interventions, the
prominences client will:  Increase the frequency  To disperse
↓ of turning (turning q2). pressure over
Compresses  Experience Position the client to time or
capillaries & healing of stay off the ulcer. If decreasing the
occludes blood ulcer/regain there is no turning tissue load
flow skin integrity surface without a
↓ (reduce size of pressure ulcer, use a
Pressure not ulcer) pressure redistribution
relieved  Reduce risk for bed & continue
↓ infection turning the client
Microthrombi  Elevate heels off the  Heel covers do not
formation bed by using pillows or relieve pressure,
↓ heel elevation botts. but they can
+ occlusion in reduce friction.
capillaries &  Maintain head of bed
blood flow @ the lowest  To prevent further
↓ elevation, if client occurrence of
Formation of must have the head pressure ulcer.
blister elevated to prevent
↓ aspiration, reposition
Rupture of to 30 degree lateral
blister position. Use seat
↓ cushions & assess
+ open wound sacral ulcers daily.
 Follow body substance  To reduce risk of
isolation precautions; infection
use clean gloves &
clean dressing for
wound care.
Practicing proper hand
washing before & after
wound care.

Dependent/Collaborative:

 Ensure adequate  To prevent

dietary intake. Review malnutrition &
dietician’s delayed healing
recommendations.
 Prevent the ulcer  To 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.
contamination/spr
ead of infection
 To promote
wound healing on
clients who do not
have adequate
calories.

 Provide oral  Pressure ulcers

supplementations, tube- cannot heal in
feedings or clients with severe
hyperalimentation to malnutrition.
achieve positive nitrogen
balance.
 Remove devitalized  To promote faster
tissue from the wound healing & reduce
bed, except in the infection
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.