hey everyone!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! problem statement: 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.goals:tissue integrity and skin will be intact.patient will remain free of pressure soars (ulcers).patient's skin will remain free of lesions.nursing interventions: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.rationale: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.
Daytonite, BSN, RN 4 Articles; 14,603 Posts Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience. Oct 20, 2009 i would describe "slightly limited sensory perception" more specifically.tissue integrity and skin will be intact.patient will remain free of pressure soars (ulcers).patient's skin will remain free of lesions.. . .are all the same thing stated 3 different ways. "soars" is spelled wrong. your goals should reflect what you expect will happen if your interventions are carried out. for example: 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. your goal connected with that intervention might be that the skin will remain dry and free of moisture. what is an appropriate skin protectant? state which skin protectant should be used. also, each goal must have 4 elements:a behaviorconditions under which the behavior needs to occurmeasurable criteriaa time frame in which the goal needs to occurpressure ulcers usually develop over bony prominences of the body.this is not true unless there is also pressure.
2bNurse-88 90 Posts Has 7 years experience. Oct 20, 2009 Thank you!where I wrote "pressure ulcers usually develop over bony prominences" I got that straight under the book for rationale, in the NANDA book.
Daytonite, BSN, RN 4 Articles; 14,603 Posts Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience. Oct 20, 2009 The book is merely a guide. You shouldn't be copying it word for word. You should be thinking about what you are writing down and what it means.
