During my assessment today I found a new stage 1 pressure ulcer on my patient. (I did report this to the nurse and wound nurse). I'm writing my care plan and looking to see if my goal is acceptable. I'm in block 1, btw.
My Nanda statement is:
Impaired skin integrity r/t pressure AEB unblanchable errythema present over sacral area.
I was thinking of a short term goal of: Patient will not have worsening of current pressure ulcer stage.
She's in the old-old category, very frail, very underweight and on hospice, so I don't feel like a goal of 'regaining skin integrity' is realistic on my time line as she's very agitated and not alert and oriented enough to follow directions to stay in the turned position we put her in. She also doesn't eat much so her protein intake probably isn't very good, so healing may be an issue.
Wanted to add that I found an article HERE
(about half way down) with some info about the focus of wound treatment for patients at the end of life with a citation to the original article.
"For patients with short life expectancy, inadequate nutrition, and poor tissue perfusion, treatment goals can shift from a primary focus on healing to patient comfort and prevention of complications, reducing pain, managing exudate and odor, and providing for optimal functional capacity (McDonald & Lesage, 2006