NCP

RLE 4
CUES AND CLUES
OBJECTIVE:
 Age: 86 y/o
 Dry skin
 Presence of pressure ulcer at the back
 Left side was completely paralyzed
 Unable to ambulate
 Stiffened left elbow joint, wrist and digital bones
 Stiffened left leg
 Foot drop (left)
NURSING DIAGNOSIS:

Impaired skin integrity related to prolonged immobility

OBJECTIVES:
 After 3 hours of nursing intervention, the relatives of the client will be able to:

 Perform passive range of motion to client;

 Verbalize understanding of causative factors;
 Participate demonstration of preventive measures to client;
OBJECTIVES:
 After 1-2 weeks of nursing intervention, the client will be able to:

 Display timely wound healing of pressure sores without much complications;

 Maintain optimal physical well-being;
 Be free of joint contractures;
INTERVENTIONS:

 Handle client carefully, (ex: during positioning and transfer)

 Inspect skin on a daily basis, describing lesion characteristics and changes observed
 Remove wet/wrinkled linens promptly

 Keep area clean and dry at all times

 Use appropriate padding devices (soft

mattresses or egg crate mattresses)
 Encourage relatives to perform passive
range of motion

 Do frequent changes of position (turning to

sides)