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NCP [Impaired Skin Integrity]

NCP [Impaired Skin Integrity]

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Published by: hebrewprincess on Jan 02, 2010
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01/01/2013

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ASSESSMEN
T
NURSING
DIAGNOSIS
RATIONALE
OBJECTIVES
NURSING INTERVENTIONS
RATIONALE
EVALUATION

Subjective:
\u201cmeron na
syang sugat
sa bandang
pwet, dahil sa
pagkakahiga
niya ng
matagal..\u201d as
verbalized by
the patient\u2019s
granddaughte
r.

Objectives:
\ue000Stage II
pressure
ulcer @ L
& R
buttocks
\ue000Localized

injury over
bony
prominenc
e

\ue000Dry &
shallow
wound
\ue000Reddish-

pink
open/ruptu
re blister

P- Impaired
Skin Integrity
E- related to
pressure
ulcer
secondary to
prolonged
immobility
and
unrelieved
pressure as
S- evidenced
by:

\ue000Stage II
pressure
ulcer @ L
& R
buttocks
\ue000Localized

injury over
bony
prominenc
e

\ue000Dry &
shallow
wound
\ue000Reddish-

pink
open/ruptu
re blister

Pressure on
soft tissues
between
bony
prominences
\u2193
Compresses
capillaries &
occludes
blood flow
\u2193
Pressure not
relieved
\u2193
Microthrombi
formation
\u2193
+ occlusion
in capillaries
& blood flow
\u2193
Formation of
blister
\u2193
Rupture of
blister
\u2193
+ open
wound
\u2193
Stage II
manifestation
s:

\ue000Stage II
pressure
ulcer @ L
& R
buttocks
\ue000Localized
injury over
Short Term:

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

\ue000Have reduced

risk of further
impairment of
skin integrity

\ue000

Patient\u2019
s caregivers
will
demonstrate
understandin
g & skill in
care of
wound

Long Term:
After 3-4 days

of nursing
interventions,
the client will:

\ue000Experience

healing of
ulcer/regain
skin
integrity
(reduce size
of ulcer)

\ue000Reduce risk
for infection
Independent:
\ue000Assess between folds of

skin, remove anti embolic
stockings or devices & use
a mirror to see the heels.
Also assess under oxygen
tubing especially on the
ears & the cheek, beneath
splints and under medical
devices.

\ue000Note objective data of

pressure ulcer (stage,
length, width, depth,
wound bed appearance,
drainage & condition of
periulcer tissue)

\ue000Increase the frequency

of turning (turning q2).
Position the client to stay
off the ulcer. If there is no
turning surface without a
pressure ulcer, use a
pressure redistribution
bed & continue turning
the client

\ue000Elevate heels off the
bed by using pillows or
heel elevation botts.
\ue000Maintain head of bed @

the lowest elevation, if
client must have the head
elevated to prevent

\ue000Pressure

ulcers under
medical
devices are
commonly
overlooked.

\ue000Reassessment

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.

\ue000To disperse

pressure over
time or
decreasing
the tissue
load

\ue000Heel covers do

not relieve
pressure, but
they can
reduce
friction.

\ue000

To
prevent
further
occurrence of

\ue000After 8 hrs of

nursing
interventions
patient:

-reduced risk

of further
impairment of
skin integrity
as evidenced
by no actual
additional
tissue

breakdown &

no persistent
reddened
areas

-patient\u2019s
caregivers
demonstrated
understanding
& skill in care
of wound as
evidenced by
checking
pressure ulcer
sites
frequently &
cleansing the
wound
aseptically.

PARTIALLY
MET
\ue000After 4 days of

nursing
interventions
the client:

-Experienced
healing of

bony
prominenc
e

\ue000Dry &
shallow
wound
\ue000Reddish-

pink
open/ruptu
re blister

Reference:
Medical-
Surgical
NursingClini
cal
Managemen
t for Positive
Outcomes
Vol II, 8th
edition by
Joyce M.
Black pp.
1209-1210

aspiration, reposition to
30 degree lateral position.
Use seat cushions &
assess sacral ulcers daily.

\ue000Follow body substance

isolation precautions; use
clean gloves & clean
dressing for wound care.
Practicing proper hand
washing before & after
wound care.

Dependent/Collaborative:
\ue000Ensure adequate dietary
intake. Review dietician\u2019s
recommendations.
\ue000

Prevent the ulcer from
being exposed to urine &
feces. Use indwelling
catheters, bowel
containment systems, &
topical creams or dressings.

\ue000Supplement the diet with

vitamins & minerals.
Vitamins C and zinc are
commonly prescribed.

\ue000

Provide oral
supplementations, tube-
feedings or
hyperalimentation to achieve
positive nitrogen balance.

\ue000Remove 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

pressure ulcer.
\ue000To reduce risk
of infection
\ue000To prevent

malnutrition &
delayed
healing

\ue000To prevent

contamination/
spread of
infection

\ue000 To promote

wound healing
on clients who
do not have
adequate
calories.

\ue000 Pre s s ur e

ulcers cannot
heal in clients
with severe
malnutrition.

\ue000To promote

faster healing
& reduce
infection

tissue as
evidenced by
development
of granulation
tissue &
decrease in
ulcer size.

- Reduce risk of
infection as
evidenced by
observing
proper hand
washing
technique
before & after
wound care.

PARTIALLY
MET

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