Nursing Care Plans

[kmp23]

Hey Guys!

I just wanted to see if I am on the right track for a nursing care plan also I don't know about the long term goal (if its any good)... Thanks for your help!

K

Actual: Impaired skin integrity related to malnutrition and physical immobilization evidenced by stage 1 pressure ulcer on sacral area.

Short term goals:

-Patient will maintain skin intact with no signs of further breakdown by change of shifts.

Interventions:

-Frequently repositioning the patient every 2 hours or as patient requests.

Rationale: "Reduces the duration and intensity of pressure." (Perry, Potter, Elkin, 2012)

-Assess the patient's nutrition status

Rationale: "Deficiencies in any nutrient results in impaired or delayed healing." (Potter & Perry, 2013, p. 1184)

-Monitor patient's incontinence status and minimize exposure of moisture to area.

Rationale: "...exposure to gastric and pancreatic drainage has the highest risk for skin breakdown. " (Potter & Perry, 2013, p. 1189)

Evaluation: Hypothetically,

Long term goals:

-Patient will verbalize the importance of good skin integrity by discharge.

Interventions:

-Educate patient on the importance of nutrition and eating a well balanced diet.

Rationale: "A balanced intake of various nutrients (i.e., protein, fat, carbohydrates, vitamins, and minerals) is critical to support wound healing." (PP 2013, p.1186)

-Educate patient on the importance of hydration.

Rationale: "dehydration can affect albumin levels and tissue integrity." (PPE, 2012 p. 613)

-Patient will tell me in detail what is the cause of breakdown in skin.

Rationale:

Evaluation: Hypothetically, I would teach the patient the interventions needed to protect against further skin breakdown and promote good skin integrity.

[nurseprnRN, BSN, RN]

kmp23 said:

Actual: Impaired skin integrity related to malnutrition and physical immobilization evidenced by stage 1 pressure ulcer on sacral area.

Short term goals:

-Patient will maintain skin intact with no signs of further breakdown by change of shifts.

Interventions:

-Frequently repositioning the patient every 2 hours or as patient requests.

Rationale: “Reduces the duration and intensity of pressure.” (Perry, Potter, Elkin, 2012)

-Assess the patient’s nutrition status

Rationale: “Deficiencies in any nutrient results in impaired or delayed healing.” (Potter & Perry, 2013, p. 1184)

.

Good diagnosis, though "malnutrition" does not appear on the list of approved related factors (p.436 in your handy-dandy NANDA-I 2012-2014). "Imbalanced nutritional state" does, though.

Many students see "assessment" as an intervention. However, alas, assessing, while important, will not affect this lady's skin a whit. Consider adding an intervention which optimizes her nutrition and say how you'll know it's OK/better/improving.

kmp23 said:

-Monitor patient’s incontinence status and minimize exposure of moisture to area.

Rationale: “…exposure to gastric and pancreatic drainage has the highest risk for skin breakdown. ” (Potter & Perry, 2013, p. 1189)

Evaluation: Hypothetically, .

Does this lady have gastric or pancreatic drainage at her sacrum? If not, see if you can find a quote that talks about general moisture/urine/stool/diphoresis, shear, and other causative factors (see p. 436 for a bunch of them)

kmp23 said:

Long term goals:

-Patient will verbalize the importance of good skin integrity by discharge.

Interventions:

-Educate patient on the importance of nutrition and eating a well balanced diet.

Rationale: “A balanced intake of various nutrients (i.e., protein, fat, carbohydrates, vitamins, and minerals) is critical to support wound healing.” (PP 2013, p.1186)

-Educate patient on the importance of hydration.

Rationale: “dehydration can affect albumin levels and tissue integrity.” (PPE, 2012 p. 613)

-Patient will tell me in detail what is the cause of breakdown in skin.

Rationale:

Evaluation: Hypothetically, I would teach the patient the interventions needed to protect against further skin breakdown and promote good skin integrity.

So... by the time she goes home, she'll know all about that...but is she healed? ?

Did she come into the hospital with a skin breakdown, or did we give it to her? I think it likely that if she is well enough to go home and resume normal movement, clothing, bathroom use, bathing, and so forth, she won't be at such risk anymore. So while it's great to be sure she knows to take better care of herself from a nutritional point and from an injury-avoidance point, I think your first priority is to see that she heals to intact skin under our care.

All in all, a credible first effort. If you don't have the NANDA-I 2012-2014, you are exactly the kind of well-prepared student who would get the most out of it. ?

[kmp23]

Thank you for your reply! I took all you things into consideration and changed up a few things :)