NURSING CARE PLAN

Date/
Time/ CUES NEED NURSING OBJECTIVE OF NURSING RATIONALE EVALUATION
Shift DIAGNOSIS CARE INTERVENTION
Nov Objective: N Risk for At the end of the 1) Inspect skin, Skin is at risk Goal met.
28 U impaired skin 8-hour shift, noting bony because of At the end of the
2016 1) Prolonged T integrity r/t patient will prominences, impaired 8-hour nursing
lying on bed R prolonged bed maintain skin presence of edema, peripheral care, patients
73 I rest and integrity. areas altered circulation, skin remained
2) Patients T decreased tissue circulation/pigment physical intact.
inability to I perfusion. ation, or immobility,
turn to side to O obesity/emaciation. and alterations
side without N in nutritional
assistance A status.
L
3) Scaly/flaky - 2) Provide gentle Improves
skin M massage around blood flow,
E reddened or minimizing
4) Generalized T blanched areas. tissue hypoxia.
Weakness A
B 3) Reposition Reduces
O patient every 2 pressure on
L hours. tissues,
I improving
C circulation and
reducing time
P any one area is
A deprived of
T full blood
T flow.
E
R 4) Provide frequent Excessive
N skin care; minimize dryness or
contact with moisture
moisture/excretions damages skin
and hastens
breakdown.

5) Provide Reduces
alternating pressure pressure to
skin, may
improve
circulation.

6) Maintain Hydrated skin

adequate nutrition is less prone to
and hydration break down.

7) Encourage use These

of lift sheet to measures
move patient and reduce
discourage shearing forces
caregiver from on the skin.
elevating HOB
repeatedly.

8) Monitor skin Systemic

condition at least infection can
once a day for identify
color or texture impending
changes, problems early.
dermatological
conditions, or
lesions.
Keeping the
9) Always keep bed wrinkle
linens of the bed free lessens the
and mattress probability of
wrinkle free. developing
pressure sores.

Placing a
10) Place a pillow gauze or
or gauze on bony pillow will
prominences when lessen the
patient is lying on pressure in
his back. accumulating
on the bony
prominences.