Nursing Student Care Plan

Patient: F – 70

P: Risk for pressure ulcer development

E: related to Braden scale score less than 18 (actual score 12)

S: as evidenced by incontinence, immobility and increased chance for friction/shearing injury.

Goal: Maintain skin integrity and prevent pressure sores

Evaluation of outcomes and

Expected Outcomes
The client will:
Report any altered sensation or pain
of skin daily during AM care.
Remain free from any redness over
bony prominences
Client will allow staff to assist them
in repositioning every 2 hours to
relieve pressure from bony
prominences.
Verbalize understanding of plan to
reduce pressure ulcer risk to nurse
immediately after discussion of care
plan.
Nursing Interventions
The nurse will:
Assessment: Every 3 months and as
needed for status change use the
Braden scale to evaluate risk for skin
breakdown.
Treatment: Work with UAP to assess
skin daily and report/record any
abnormalities and reposition client
every 2 hours.
Client/Family Education: educate
client on proper skin care, letting
staff know of incontinent episodes
and use of skin barrier products.
Discharge planning: Initiate a
consultation with wound
nurse/specialist and/or continence
nurse.
Rationale for interventions
Targeting variables focuses assessment on
particular risk factors to guide plan of
care/prevention (Ackley & Ladwig, 691)
Assessment/treatment and proactive
intervention reduce risk for tissue injury
and additional pain/treatment for client
(Ackley & Ladwig, 691)
Skin barrier products help reduce
moisture associated skin irritation that can
increase pressure ulcer risk (Ackley &
Ladwig, 693)
It may be beneficial to initiate a
consultation to establish a comprehensive
plan for pressure ulcer risk reduction for
clients at high risk for skin breakdown
(Ackley & Ladwig, 693)
client response to
interventions
Client notified nurse of altered
sensation on gluteal fold.
The client has remained free
from any redness on bony
prominences.
The UAP repositions client every
2 hours.
The client understands and is
accepting of the need to be
repositioned frequently, the
need to report any altered
sensations and the need to go to
consultations as recommended.