Wk4-Nursing Care Plan - exampled of a care plan PDF

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exampled of a care plan...

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Nursing Care Plan Analysis of Assessment .

Resident is 84 years old and presents with impaired skin integrity. According to Ackley, impaired skin integrity is defined as altered epidermis and/or dermis. (A, 836) Resident has 2 superficial open areas on inner buttocks/coccyx area. One open area measuring 0.2 cm x 0.3 cm. Second open area is 0.3 cm below the first open area and measuring approximately 0.2 cm x 0.3 cm. Resident is incontinent of bowel. According to Iggy, bowel incontinence is defined as an involuntary control of bowels. (Iggy, 18) Resident is unable to walk and needs a 2 assist with a full body mechanical lift for all transfers. According to

Nursing Diagnostic Statement

Nursing Diagnosis: Impaired Skin Integrity

SMART Outcomes

1. Resident will rate pain a 0 on a 0-10 scale at site of skin impairment during my shift. 2. Resident will regain skin integrity by 12/10/19.

Interventions with Rationales and References

Assess site of skin impairment once a day for color changes, redness, swelling, warmth, pain, or other signs of infection. Determine whether the resident is experiencing changes in sensation or pain. Rationale: Systemic inspection can identify impending problems early. (A, 838)

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Related to: (etiology or cause)

pressure from immobility, incontinence of bowel

Toilet resident every 2 hours or as needed and use barrier cream. Rationale: Implementing an incontinence prevention plan with the use of skin protectant or a cleanser protectant can significantly decrease skin breakdown and pressure injury formation. (A, 838) 

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Reposition resident when in bed every 2 hours using pillows to position. Do not position resident directly on site of skin impairment.

Taylor, the impaired circulation that accompanies immobility may result in serious skin breakdown. (T, 1145) Resident has a score of 13 on The Braden Scale for Predicting Pressure Sore Risk. According to Taylor, a score of 13 is moderate risk for a pressure sore. Resident states, “I have no pain on my bottom.” Resident rates pain a “0” on a 0-10 scale.

AEB or MB: (defining characteristics)

Rationale: Repositioning every 2 hours will reduce the pressure on site of skin impairment and will help the healing process.

2 superficial open areas, pink wound beds, noted 0.2 cm x 0.3 cm with another open area approximately 0.3 cm below which measures 0.2 cm x 0.3 cm

Evaluation of Outcome Achievement (Met or not met and changes/recommendations with nursing interventions): Outcomes have been met. Resident rate pain a “0” on a 0-10 scale for the whole shift. Upon assessing the resident’s coccyx/buttocks I noticed that both open areas have been healed. Skin surrounding the buttocks/coccyx area is red and blanchable with no sores. I checked and changed residents depends every 2 hours during shift and applied barrier cream. Throughout the shift I repositioned resident in broda chair to prevent pressure on skin. I would had another intervention for my diagnosis. The intervention that I would had would be, “Provide peri-care every time toileting resident and assuring that peri-area is dry.” Rationale: Providing peri-care every time toileting the resident and making sure that the area is dry will help decrease the breakdown of skin in that area.” Consider what type of improved nutrition would assist with wound healing?...