NCP: Impaired Skin Integrity r/t skin destruction secondary to vehicular accident

Written by adminNursing Care Plan'sFeb 13, 2011

Cues Objective: - Abrasion of wounds noted. - redness noted - pain on the affected area - with moist wound noted - Medication: Bactroban ointment Need NUTRITIONAL-METABOLIC PATTERN Diagnosis Impaired Skin Integrity related to skin destruction secondary to vehicular accident. Objectives At the end of span of care our client will be able to demonstrate progressive improvement in wound or lesion healing as evidence by: a. absence of abrasions, moist and redness of the surface of the wound; b. demonstrate behavior/lifestyle changes to promote healing and prevent complications; c. verbalize understanding on condition and causative factors. Interventions 1. note evidence of other organ or tissue involvement. R: to identify causative or contributing factors. 2. assess adequacy of blood supply and innervation of the affected tissue. R: to note the extent of injury. 3. inspect wounds or lesions daily for changes. R: promotes timely interventions/ revision of plan of care. 4. promote good nutrition with adequate protein such as fish. R: to promote faster wound healing. 5. provide adequate periods of rest and sleep. R: to minimize impairment and promote healing. 6. instruct to practice aseptic technique. R: reduces risk of cross contamination. 7. promote early mobility. Provide position changes. R: to promote circulation and prevent excessive tissue pressure. 8. discuss importance of early detection and reporting of changes in condition R: promotes early detection of the developing complication 9. administer anti-infective drugs as ordered. R: to promote wellness. 10. emphasize need for adequate nutritional or fluid intake. R: to involve patient in his own care. Evaluation

After 2 days span of care our client was able to demonstrate progressive improvement in wound or lesion healing as evidence by: a. presence of abrasions but minimal redness noted on the surface of the wound; b. demonstrate behavior/lifestyle changes to promote healing and prevent complications; patient was seen guarding behavior on the site