i need feedback and opinions on one of my nursing care plans
for my patient at clinical.
please & thank you! reason being, i really messed up my first one, did it totally wrong, and after reading a bit more and getting some help, i'm hoping i've gotten it right this time around. thanks all!
risk for impaired skin integrity related to braden scale score of 14, as evidence by complete adl assistance, very limited mobility, confinement to bed or wheelchair, occasionally moist skin, and slightly limited sensory perception.
tissue integrity and skin will be intact.
patient will remain free of pressure soars (ulcers).
patient's skin will remain free of lesions.
monitor skin condition at least once a day for color, texture, or lesions.
monitor the patients incontinence status and minimize exposure of the site of skin impairment and other areas to moisture from incontinence. use appropriate skin protectant.
monitor condition of skin over bony prominences.
reposition patient q2h.
inspection can identify impending problems early.
implementing the use of a skin protectant and minimizing exposure to effected area can significantly decrease skin breakdown and pressure ulcer formation.
pressure ulcers usually develop over bony prominences of the body.
repositioning the p/t q2h will prevent constant pro-longed pressure on the same area which can lead to a pressure ulcer.
p.s i don't have the evaluation or outcome because we havn't carried out our care plans yet.