NURSING CARE PLAN

OBJECTIVES/EVALUAT
NURSING NURSING
CUES ION RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
CRITERIA
1. Assess site of impaired tissue integrity and
Subjective: Impaired Tissue After 2 hours of nursing determine etiology (e.g., acute or chronic wound, After 2 hours of
napaakan ko sa Integrity interventions the burn, dermatological lesion, pressure ulcer, leg nursing interventions
ulcer).
among iro mam, patient will be able to the patient will be
Prior assessment of wound etiology is critical for
lalom man gud nga demonstrate measure proper identification of nursing interventions (van able to demonstrate
pagka paak. to protect and heal the Rijswijk, 2001). measure to protect
impaired tissue, 2. Determine size and depth of wound (e.g., full- and heal the impaired
Objective: including wound care. thickness wound, stage III or stage IV pressure tissue, including
-punctured dog bite ulcer). Wound assessment is more reliable when wound care, such as
performed by the same caregiver, the client is in the
-disrupted skin and cleaning the site in a
same position, and the same techniques are used
tissue (Krasner, Sibbald, 1999; Sussman, Bates-Jensen, circular manner from
-presence of swelling 1998). inside to outside, and
in the bite site cleaning the wound
3. Monitor site of impaired tissue integrity at least once with running water.
daily for color changes, redness, swelling, warmth,
pain, or other signs of infection. Determine whether
client is experiencing changes in sensation or pain.
Pay special attention to all high-risk areas such as
bony prominences, skin folds, sacrum, and heels.
Systematic inspection can identify impending
problems early (Bryant, 1999).

4. Monitor status of skin around wound. Monitor client's

skin care practices, noting type of soap or other
cleansing agents used, temperature of water, and
frequency of skin cleansing.
Individualize plan according to client's skin
condition, needs, and preferences. 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; Bergstrom, 1994).

5. Select a topical treatment that maintains a moist

wound-healing environment that is balanced with
the need to absorb exudate and fill dead space.
Caution should always be taken to not dry out the
wound (Panel for the Prediction and Prevention of
Pressure Ulcers in Adults, 1992; Bergtrom et al,
1994; Ovington, 1998).

6. Do not position client on site of impaired tissue

integrity. If consistent with overall client
management goals, turn and position client at least
every 2 hours, and carefully transfer client to avoid
adverse effects of external mechanical forces
(pressure, friction, and shear).
Evaluate for use of specialty mattresses, beds, or
devices as appropriate (Fleck, 2001). If the goal of
care is to keep the client (e.g., a terminally ill client)
comfortable, turning and repositioning may not be
appropriate. Maintain the head of the bed at the
lowest degree of elevation possible to reduce shear
and friction, and use lift devices, pillows, foam
wedges, and pressure-reducing devices in the bed
(Panel for the Prediction and Prevention of Pressure
Ulcers in Adults, 1992; Krasner, Rodeheaver, Sibbald,
2001).

7. Avoid massaging around site of impaired tissue

integrity and over bony prominences.
Research suggests that massage may lead to deep-
tissue trauma (Panel for the Prediction and
Prevention of Pressure Ulcers in Adults, 1992).
8. Assess client's nutritional status; refer for a
nutritional consultation and/or institute dietary
supplements.
Inadequate nutritional intake places the client at risk
for skin breakdown and compromises healing
(Demling, De Santi, 1998).

Client/Family Teaching

1. Teach skin and wound assessment and ways to

monitor for signs and symptoms of infection,
complications, and healing.
Early assessment and intervention helps prevent the
development of serious problems (van Rijswijk, 2001).

2. Teach use of a topical treatment that is matched to

client, wound, and setting.
The topical treatment needs to be adjusted as the status
of the wound changes (Krasner, Sibbald, 1999).

3. If consistent with overall client management goals,

teach how to turn and reposition client at least every 2
hours.
If the goal of care is to keep the client (e.g., a 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).