Impaired Skin Integrity Nursing Care Plan
Impaired Skin Integrity Nursing Care Plan
Prepared by: [YOUR NAME]
Email: [YOUR EMAIL]
Date: November 12, 2050
Patient Information
Patient Name: Garfield Williams
Age: 72
Gender: Male
Diagnosis: Stage II Pressure Ulcer on the Sacral Region
Admission Date: November 1, 2050
Room Number: 305B
Assessment
|
Assessment Area |
Details |
|---|---|
|
Skin Condition |
Stage II pressure ulcer, 4 cm x 5 cm, pink wound bed with shallow necrosis at sacral area. |
|
Risk Factors |
Limited mobility, immobility due to hip surgery, inadequate nutrition, and incontinence. |
|
Pain Level |
4/10, moderate pain reported on repositioning. |
|
Nutritional Status |
Poor appetite, weight loss of 3 kg in the last month. |
|
Mobility |
Bedridden, unable to reposition without assistance. |
Nursing Diagnosis
-
Impaired Skin Integrity related to prolonged pressure, immobility, and incontinence as evidenced by Stage II pressure ulcer on the sacral region.
-
Risk for Infection related to open wound and insufficient nutrition.
Goals and Outcomes
|
Goal |
Expected Outcome |
Time Frame |
|---|---|---|
|
Goal 1: Promote healing of the pressure ulcer. |
The pressure ulcer will decrease in size to 2 cm x 3 cm within 2 weeks. |
November 26, 2050 |
|
Goal 2: Prevent further skin breakdown. |
No new areas of skin breakdown will be observed. |
November 26, 2050 |
|
Goal 3: Minimize pain associated with the pressure ulcer. |
Pain will be reduced to a 2/10 on the pain scale by next assessment. |
November 19, 2050 |
|
Goal 4: Improve nutritional status. |
Patient will increase caloric intake by 500 calories/day. |
November 19, 2050 |
Nursing Interventions
|
Intervention |
Rationale |
Frequency |
|---|---|---|
|
Reposition patient every 2 hours |
To alleviate pressure on the sacral area and promote circulation. |
Every 2 hours |
|
Apply hydrocolloid dressing |
To protect the wound, promote moisture balance, and aid in healing. |
Daily and after dressing changes |
|
Increase protein and calorie intake |
To enhance wound healing and prevent malnutrition. |
Daily monitoring |
|
Provide incontinence care |
To prevent skin maceration and further breakdown. |
After each episode |
|
Administer pain medication as ordered |
To manage pain and discomfort related to pressure ulcer. |
As needed (PRN) |
|
Monitor for signs of infection |
To prevent infection and promote wound healing. |
Daily assessment |
Evaluation
|
Goal/Outcome |
Progress |
Date |
|---|---|---|
|
Goal 1: Promote healing of the pressure ulcer. |
The wound size reduced to 3 cm x 4 cm, showing moderate improvement. |
November 19, 2050 |
|
Goal 2: Prevent further skin breakdown. |
No new areas of skin breakdown observed. |
November 12, 2050 |
|
Goal 3: Minimize pain associated with the pressure ulcer. |
Patient reports a pain level of 2/10 on repositioning. |
November 12, 2050 |
|
Goal 4: Improve nutritional status. |
Patient’s daily caloric intake increased by 450 calories. |
November 19, 2050 |
Additional Notes
-
Patient is at high risk for additional skin breakdown due to poor nutritional status and immobility. Collaboration with dietitian and physical therapist is essential.
-
Skin condition should be reassessed weekly for any changes in wound size, appearance, or signs of infection.
