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.
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