Need help with nursing interventions

Monitor skin once a shift for color, texture changes, drainage and appearance of surrounding skin.

Assess patients nutritional status.

Traci

Monitor the client's skin care practices, noting type of soap and other cleansing agents used, temperature of water, and frequency of skin cleansing.

Avoid massaging around the site of skin impairment and over bony prominences.

Identify the client's phase of wound healing (inflammation, proliferation, maturation) and stage of injury.

Teach skin and would assessment and ways to monitor for signs and symptoms of infections, complications, and healing.

Teach the client why any topical treatments have been selected.

Hope this helps, it's straight from my nursing diagnosis book.

(Nursing Diagnosis Handbook, an evidence-based guide to planning care by Betty J. Ackley and Gail B. Ladwig eighth edition)

If you don't have this book, I highly recommend it. We got a nursing diagnosis book with our initial package of books in my first semester and it was terrible. One of my classmates had the newest version of this book, but I went online and bought an older version for a fraction of the price and there are no noticable differences (except in the quality of my care plans!). In the front of the book it has bascially an index of medical diagnoses and the nursing diagnoses that may fit. Then you turn to the page of the diagnosis and it lists goals, interventions, and rational.