I need some help with a care plan I am doing. The diagnosis is impaired skin integrity r/t excretions and/or excretions. The pt has been an inpatient for several months. She originally was admitted for fistula repair, incisional hernia repair with mesh insertion. She also has a colostomy. Her abdomen is still open and healing and has 2 pouches which have been leaking stool, which is where the dx comes from. She has been on TPA feedings with only clear liquid po. She just started solid food & ensure po.
I have several nursing interventions with rationales but need more. So far I have: teach skin & wound assessment to monitor for infections & complications; individualize plan according to pts skin condition & preferences; teach pt why a specific treatment has been selected; assess the nutritional status; obtain consult with wound/ostomy specialist; minimize the exposure of skin to moisture; encourage consuming Ensure to increase protein & therefore skin healing; monitor lab values; and use careful sterile technique.
Apparently there are a lot of interventions that I have missed. I have been working on this for a while and am getting brain freeze I guess because I feel like I'm hitting a brick wall and can't think of any more. Any help would be greatly appreciated!!!!