NURSING CARE PLAN
Client Initials: __TJ__ Medical Diagnosis: Impaired Skin Integrity________ Student’s Name: Uvbi Osatohangbon .
| Assessment
(Include THREE pieces of assessment data that relate directly to the nursing diagnosis) |
Nursing Diagnosis
(Select ONE nursing diagnosis that relates to NRSG 61 content. If you list more than one, the first nursing diagnosis listed will be used for grading. Include all 3 parts- the problem, r/t statement and AEB data) |
Goal
(List ONE goal that relates directly to the nursing diagnosis- the problem. Be sure it is SMART) |
Interventions with references
(List THREE interventions that relate to the Nursing diagnosis (the r/t statement). Be sure to include specific details and REFERENCE each intervention, using APA format). |
Rationale
(List rationale for EACH intervention) |
Evaluation
(Evaluate the goal and interventions) |
|
1. Experiences constant vomiting and diarrhea resulting in a fluid output of 750 mLs more than the intake (250 mLs)
2. His lips are dry and cracked.
3. Confirmed stage 1 pressure injury from reddish area on sacrum approximately 1.5 cm by 2 cm. |
1. Impaired skin integrity r/t to negative fluid balance evidenced by cracked and dry lips | 1. Increase patient fluid intake until positive fluid balance is accomplished by consistent monitoring of fluid intake and output each day for 6 months to try and ensure a lesser negative fluid balance each day until a positive fluid balance is reached. | 1. Monitor skin integrity (RNAO, n.d.)
2. Diet (RNAO, 2016)
3. Prevent local areas of pressure (RNAO, n.d.) |
1. Assists nurse in collecting important data required for decision making regarding potential risk factors.
2. Having a diet that promotes skin hydration will assist in decrease of negative fluid balance.
3. Reposition patient and have the patient move around more to prevent pressure injuries and promote skin integrity |
1. Evaluate the goal
Evaluate each intervention
1. Successful monitoring of patient skin on each shift
2. Successful creation of a diet taking into account client preference resulting in no complains
3. Repositioning every two hours remained consistent no new pressure injuries were found |
REFERENCES
RNAO. (n.d.). Assessment and management of pressure injuries for the Interprofessional team, third edition. Assessment and Management of Pressure Injuries for the Interprofessional Team, Third Edition | Registered Nurses’ Association of Ontario. Retrieved November 27, 2022, from https://rnao.ca/bpg/guidelines/pressure-injuries
RNAO. (n.d.). Educational Workshop for RNs and RPNs Assessment and Management of Pressure Ulcers. Login – Fleming College. Retrieved November 27, 2022, from https://fleming.desire2learn.com/d2l/le/content/178794/viewContent/2134264/View
RNAO. (n.d.). Taking the Pressure Off: Preventing & Managing Pressure Injuries. Login – Fleming College. Retrieved November 27, 2022, from https://fleming.desire2learn.com/d2l/le/content/178794/viewContent/2134262/View