ASSESSMENT

NURSING DIAGNOSIS P- Impaired Skin Integrity E- related to pressure ulcer secondary to prolonged immobility and unrelieved pressure as evidenced by:  Localized injury over bony prominence  Dry & shallow wound  Reddish-pink open/rupture blister

OBJECTIVES

NURSING INTERVENTIONS

RATIONALE

EVALUATION

Objectives:  Localized injury over bony prominence  Dry & shallow wound  Reddish-pink open/rupture blister

Short Term: After 6-8 hrs of nursing interventions of nursing interventions, the client will: Have reduced risk of further impairment of skin integrity Patient s caregivers will demonstrate understanding & skill in care of wound

Independent:  Assess between folds of skin, remove anti embolic stockings or devices & use a mirror to see the heels. Also assess under oxygen tubing especially on the ears & the cheek, and under medical devices.  Note objective data of pressure ulcer (stage, length, width, depth, wound bed appearance, drainage & condition of periulcer tissue)  Increase the frequency of turning (turning q2). Position the client to stay off the ulcer. If there is no turning surface without a pressure ulcer, use a pressure redistribution bed & continue turning the client  Elevate heels off the bed by using pillows or heel elevation botts.  Maintain head of bed @ the lowest elevation, if client must have the head elevated to prevent aspiration, reposition to 30 degree lateral position. Use seat cushions & assess sacral ulcers daily.  Follow body substance isolation precautions; use clean gloves & clean dressing for wound care. Practicing proper hand washing

 Pressure ulcers under medical devices are commonly overlooked.  Reassessment of ulcer is completed each time dressing are changed or sooner if ulcer shows manifestations of deterioration. Analyses of the trends in healing are important step in assessment.  To disperse pressure over time or decreasing the tissue load  Heel covers do not relieve pressure, but they can reduce friction.  To prevent further occurrence of pressure ulcer.

Long Term: After 3-4 days of nursing interventions, the client will:  Experience healing of ulcer/regain skin integrity (reduce size of ulcer)  Reduce risk for infection

After 8 hrs of nursing interventions patient: - reduced risk of further impairment of skin integrity as evidenced by no actual additional tissue breakdown & no persistent reddened areas - patient s caregivers demonstrated understanding & skill in care of wound as evidenced by checking pressure ulcer sites frequently & cleansing the wound aseptically. PARTIALLY MET After 4 days of nursing interventions the client: - Experienced healing of tissue

before & after wound care. Dependent/Collaborative: Ensure adequate dietary intake. Review dietician s recommendations. Prevent the ulcer from being exposed to urine & feces. Use indwelling catheters, bowel containment systems, & topical creams or dressings. Supplement the diet with vitamins & minerals. Vitamins C and zinc are commonly prescribed. Provide oral supplementations, tube-feedings or hyperalimentation to achieve positive nitrogen balance. Remove devitalized tissue from the wound bed, except in the avascular tissue or on the heels. Began by cleansing the ulcer bed with normal saline, then use appropriate technique for debridement. Once the ulcer is free of devitalized tissue, apply dressing the keep the wound bed moist & the surrounding skin dry. Do not use occlusive dressings on ulcer.  To reduce risk of infection

 To prevent malnutrition & delayed healing  To prevent contamination/sp read of infection

as evidenced by development of granulation tissue & decrease in ulcer size. - Reduce risk of infection as evidenced by observing proper hand washing technique before & after wound care. PARTIALLY MET

 To promote wound healing on clients who do not have adequate calories.  Pressure ulcers cannot heal in clients with severe malnutrition.  To promote faster healing & reduce infection