Nursing Care Plan On Impaired Skin Integrity

NURSING CARE PLAN on Impaired Skin Integrity Nursing Diagnosis: Delayed wound recovery due to ineffective therapeutic regimen management and self-care deficit as evidenced by low self-esteem and impaired physical mobility. Goals After the process the patient will: 1.

Have a good and healthy skin condition.

2.

Be able to coop with the activities of Daily Living (ADL) and will function normally.

3.

4.

Expected Outcomes The patient are expected to: •

•

Have a proper and effective therapeutic management of such conditions. Be knowledgeable of such conditions and the ways of treating and preventing them.

•

Know the causes of his/her condition and follow steps on the proper therapeutic management. Be confined for bed rest for about 2-3 weeks or more with controlled mobility on the affected part, that is towards recovery. Within 24 hours or less the patient can express feeling of relief and satisfaction upon the treatment of his condition.

Nursing Interventions

Implementation

1. Discuss pain control measures if needed. • To help patient coop towards the proper pain management thus minimizing pain suffering and the ways of treating them.

Patient will be assist at least twice a day observing on wound condition and any observable changes.

2. Discuss Importance of adequate nutrition (especially fluids, proteins, vitamins B and C, iron and Calories). • These provide patient information how nutrition could elevate his chances of a faster recovery and wound healing. 3. Demonstrate appropriate positions for pressure relief. • Enable client to minimize further skin trauma thus promoting wound healing and establish physical mobility. 4. Establish a turning or repositioning schedule • This provide patient’s a guide towards a proper skin management technique minimizing more skin trauma and also giving the patient something to do thus promoting self-esteem. 5. Instruct in wound assessment and provide mechanism for documenting • Necessary to gather more data concerning the patient’s condition thus identifying skin problems clearly and promoting self-esteem.

Will be repositioned on bed at least three times a day, from 6am – 12pm – 6pm. There will be a change of shift report twice a day necessary to obtain an update. Record every vital and observable signs or changes within the patient and entire unit.

Evaluations

•

Fully recover within a month of continued therapy and retain selfesteem.

6. Emphasize principles of asepsis, especially hand washing and proper methods of handling used dressings. • To avoid possible infection thus hindering the wound healing process. 7. Provide information about signs of wound infection and order complications to report. • Elevate the chances of faster wound healing which is important towards avoiding further complications or early detections that requires immediate interventions. 8. Demonstrate wound care technique such as wound cleansing and dressing changing. • To provide the patient on the correct procedures and techniques of wound caring. 9. Identify potential sources of skin trauma and means of avoidance. • Necessary to anticipate future events thus avoiding unexpected complications or changes vital to the patient’s condition. 10. Support the use of appropriate defense mechanism. • To asses patient upon the proper management of stress or depressions concerning on his condition. 11. Encourage verbalization of feelings, perceptions and fears. • To evaluate patients perceptions upon his condition and giving us information towards assessing client problems.