ASSESSMENT DIAGNOSIS

RATIONALE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

S: Palagyan naman po ng ointment yung sa gilid po ng puwet ni nanay, nagkasugat na kasi sa may puwetan nya. O: Patient s skin surface has disruption with a length of 15 inches with wound on the left cheek of the buttocks.

Risk for Impaired Skin Integrity r/t physical immobilizati on as manifested by bed sores

Immobility, which leads to pressure, shear, and friction, is the factor most likely to put an individual at risk for altered skin integrity. Advanced age; the normal loss of elasticity; inadequate nutrition; environmental moisture, especially from incontinence; and vascular insufficiency potentiate the effects of pressure and hasten the development of skin breakdown. Groups of persons with the highest risk for altered skin integrity are the spinal cord injured, those who are confined to bed or wheelchair for

After 8 hours of nursing care intervention, client/family member will be able to: -exhibit timely healing of pressure sores -apply proper wound care

-Assess general condition of the skin -Assess for -Skin stretched edema tautly over edematous tissue is at risk for impairment.

After 8 hours of nursing care intervention, client/family member was able to: -exhibited timely healing of pressure sores

-Assess for fecal -Use of diapers and and/or urinary incontinence pads incontinence. with plastic liners traps moisture and -applied proper hastens breakdown. wound care -Apply appropriate dressing such as gauze -Replace new diapers if needed -for wound healing

-Use of diapers and incontinence pads with plastic liners traps moisture and hastens breakdown. -prevents sweating

-Apply powder to around the

affected site -Administer clindamycin and topical medications -Assist nurse/health care provider when mobilizing the patient -for more rapidly healing. and those who have altered sensation that triggers the normal protective weight shifting. those with edema. aid in skin healing -For easier work -Report -to assist in evaluation of the developing plan of wound to other care health care team -Teach family -for independent member on promotion of healing proper caring of the wound and application of ointment .prolonged periods of time.

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