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    Omaima Khmis
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    1) The patient has an impaired skin integrity diagnosis due to an infected pressure ulcer on her buttocks. The short term goal is to reduce the risk of further skin impairment after 6 hours of interventions. 2) Nursing orders include repositioning the patient frequently, performing wound care, encouraging nutrition and hydration, and providing a nutrition supplement. 3) After 6 hours the goal was met as the patient's risk of further skin impairment was reduced, as evidenced by no additional tissue breakdown.

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    1) The patient has an impaired skin integrity diagnosis due to an infected pressure ulcer on her buttocks. The short term goal is to reduce the risk of further skin impairment after 6 hours of interventions. 2) Nursing orders include repositioning the patient frequently, performing wound care, encouraging nutrition and hydration, and providing a nutrition supplement. 3) After 6 hours the goal was met as the patient's risk of further skin impairment was reduced, as evidenced by no additional tissue breakdown.

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    © All Rights Reserved
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    4 views2 pages

    Assessment

    Uploaded by

    Omaima Khmis
    1) The patient has an impaired skin integrity diagnosis due to an infected pressure ulcer on her buttocks. The short term goal is to reduce the risk of further skin impairment after 6 hours of interventions. 2) Nursing orders include repositioning the patient frequently, performing wound care, encouraging nutrition and hydration, and providing a nutrition supplement. 3) After 6 hours the goal was met as the patient's risk of further skin impairment was reduced, as evidenced by no additional tissue breakdown.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    of 2

    Assessment Nursing Diagnoses Goals / Nursing Rationale (1 Evaluation (1

    (Actual) (2 Outcome orders/interventions (5 mark) mark)


    marks) Criteria Marks)
    (1 mark)
    Impaired Skin Integrity related to Short term : 1. Encourage frequent 1. Repositioning the patient The goal was met:
    pressure ulcer as evidenced by After 6 hours of nursing repositioning frequently can help to
    Subjective data: patient has infected pressure ulcer intervention the patient distribute pressure more After 6 hrs of nursing
    on her buttocks. will reduced risk of evenly across the body, interventions patient reduced risk
    further impairment of decreasing the risk of of further impairment of skin
    skin integrity. developing bed ulcers integrity as evidenced by no
    Objective data: 2. Perform necessary wound care additional tissue breakdown .
    Temperature: 38.7 C. 2. roper cleansing and
    Pulse: 88 beat/minute application of ointments,
    Respiratory Rate: 15 sprays, foams, and
    breath/minute dressings will aid in healing
    BP:120/80 mm/Hg. Long term: and the prevention of
    presence of infected pressure After 4 hours of nursing further breakdown.
    ulcer on her buttocks intervention the patient 3. Encourage nutrition and
    will experience healing hydration. 3. Protein intake, vitamins
    of pressure ulcer . A, C & E, and zinc support
    wound healing . Enteral
    nutrition and IV fluids may
    be necessary for adequate
    4 Provide local wound care nutrition.

    4. Patient is prone to sore


    5. Provide nutrition supplement as and/or bleeding gums and
    nutritionist order bad taste in mouth, which
    contributes to anorexia

    5.help in increase calories


    and protein

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