Assessment S>Ø O>disrupted skin surface >destructed skin layers >invasion of body structures >(+)blisters >partialthickness skin loss

>open lesions >w/ adherent necrotic tissue

Nursing Diagnosis Impaired skin Integrity related to Prolonged Bed Rest secondary to Immobility

Scientific Explanation The patient experiences Immobility because of prolonged bed rest which causes pressure ulcers or any lesion caused by unrelieved pressures that result in damage to underlying tissue. It occurs when tissue is between bony prominence and hard surface such as mattress. The pressure compresses small blood vessels and leads to ineffective tissue perfusion that causes tissue hypoxia and eventually cell death.

Planning After the shift the patient will receive appropriate wound care and display timely healing of skin lesions.

Intervention  Assess skin over bony prominen ces.

Rationale  To determine skin breakdown for possibility of ischemia as result of compression of skin capillaries between hard surface and the bone.

Evaluation At the end of the shift the patient received appropriate wound care and display timely healing of skin lesions as evidenced by experienced healing in pressure ulcers and pressure reduction and has controlled risk factors to prevent additional ulcers. 

Assess ability to move such as turn over the bed.  Apply a flexible hydrocoll oid dressing.  Apply wet-drysolution dressing.  Dress wound w/ calcium gluconate. 

Immobility is the major risk for skin breakdown. 

To prevent friction and shear. 

To loosen eschar by autolysis.  Assist in healing through calciumsodium ion exchange at the wound bed.

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