Nursing care plan for clinical and lecture PDF

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Nursing care plan for clinical and lecture...

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– PAUL M. WILES SCHOOL OF NURSING Joyce E. Glass ADN Program NUR 211 NURSING CARE PLAN

FORSYTH TECH

Student Name: Patricia Ervin Nursing Diagnosis: Impaired Skin Integrity Related To: open wounds on LLE. As Manifested By: stage 2 pressure injury Outcome(s): Client will not have any further skin breakdown during the hospitalization. -Client’s wounds will be kept clean and free from any further infection. Nursing Intervention Client will be repositioned every 2 hours Inspect and monitor site of skin impairment at beginning and end of shift for color changes, redness, signs of infection. Determine whether client is experiencing changes in sensation or pain by palpating area during site monitoring. Maintain good skin hygiene during shift, use skin barrier protectant with dressing change.

Rationale Prevention of skin break down. Relieving pressure aids in maintenance of skin integrity The incidence of skin breakdown is directly related to the number of risk factors present

New Interventions for 2nd day

Clients with decreased sensation are unaware of unpleasant stimuli and do not shift weight, thereby exposing the skin to excessive pressure. Implementing good hygiene and using barrier skin protectant can significantly decrease the risk of pressure damage.

Evaluation: Goals met Nursing Diagnosis: Impaired mental status Related To: metabolic imbalance As Manifested By: acute metabolic syndrome and electrolyte imbalance Outcome(s): Client’s Neurological status will be stable Nursing Interventions Monitor vital signs q4h

Assess patient’s level of consciousness and changes in behavior Assess mental status during hourly rounds. Frequently orient patient to time, place and date. Limit noise and environmental stimulation

Evaluation. Goals met Summer 2012

Rationale Electrolyte imbalance can lead to clinical manifestations i.e., respiratory failure, arrythmias and altered mental status To provide baseline for comparison with ongoing assessment findings and to detect any improvement or decline inpatient’s neurologic status Imbalances of Na, K can lead to neurological disturbances To maintain orientation To prevent additional confusion

New Interventions for 2nd day...