NURSING CARE PLAN

Assessment Explanation of Objective Intervention Rationale Evaluation /Expected

the problem outcome

Subjective: Short term :

---------- Altered epidermis After 8 hours of nursing
and/or dermis Within 8 hours of nursing 1. Inspect all skin areas, 1. Skin is especially prone interventions the patient:
Objective: interventions the patient will: noting capillary to breakdown because of 1.Is able to identify
 Weak 1. Identify individual risk blanching/refill, redness, changes in peripheral individual risk factors.
 Poor skin factors. and swelling. Pay circulation, inability to
turgor reference: 2. Verbalize particular attention to sense pressure, 2.Verbalized understanding
 On complete NANDA understanding of back of head and folds immobility, altered of treatment needs.
bed rest treatment needs. where skin continuously temperature regulation.
Immobile 3. Participate to level of touches. 3.Participated to level of
>VS taken as follows: ability to prevent skin ability to prevent skin
T: 37.2 breakdown. 2. Elevate lower extremities 2. breakdown.
Enhances venous return.
PR: 83 periodically, if tolerated.
Long term: Reduces edema
RR: 21
formation.
BP: 130/190
The patient will not exhibit
signs of bedsores. 3. Massage and lubricate
skin with bland 3. Enhances circulation and
NURSING lotion/oil. Protect protects skin surfaces,
DIAGNOSIS pressure points by use of reducing risk of
impaired skin integrity heel/elbow pads, lamb’s ulceration. Tetraplegic
related to inadequate wool, foam padding, egg- and paraplegic patients
circulation secondary crate mattress. require lifelong
to immobility. protection from
decubitus formation,
which can cause
extensive tissue necrosis
 and sepsis.
4. Reposition frequently,
whether in bed or in
sitting position. Place in 4. Improves skin circulation
prone position and reduces pressure
periodically. time on bony
prominences.
5. Wash and dry skin,
especially in high
moisture areas such as
perineum. 5. Clean, dry skin is less
prone to excoriation/
breakdown.
6. Keep bedclothes dry and
free of wrinkles, crumbs.

6. Reduces/ prevents skin

7. Provide kinetic therapy irritation.
or alternating-pressure
mattress as indicated.

7. Improves systemic and

peripheral circulation and
decreases pressure on
8. Avoid/limit injection of
skin, reducing risk of
medication below the
breakdown.
level of injury.

8. Reduced circulation and

sensation increase risk of
9. Encourage continuation
delayed absorption, local
of regular exercise
reaction, and tissue
program.
necrosis.
9. Stimulates
circulation,
enhancing cellular
nutrition/
oxygenation to
improve tissue
health.