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The document provides a nursing care plan for a patient with a pressure ulcer. The plan includes goals of maintaining intact skin and healing the existing pressure ulcer. Interventions are outlined to prevent further skin breakdown and promote wound healing. These include risk assessment, repositioning, keeping the skin moist and clean, debriding the wound as needed, applying dressings, ensuring adequate nutrition, teaching self-care, and consulting specialists if required. Progress will be monitored by assessing factors like skin integrity, wound characteristics, and drainage.
The document provides a nursing care plan for a patient with a pressure ulcer. The plan includes goals of maintaining intact skin and healing the existing pressure ulcer. Interventions are outlined to prevent further skin breakdown and promote wound healing. These include risk assessment, repositioning, keeping the skin moist and clean, debriding the wound as needed, applying dressings, ensuring adequate nutrition, teaching self-care, and consulting specialists if required. Progress will be monitored by assessing factors like skin integrity, wound characteristics, and drainage.
The document provides a nursing care plan for a patient with a pressure ulcer. The plan includes goals of maintaining intact skin and healing the existing pressure ulcer. Interventions are outlined to prevent further skin breakdown and promote wound healing. These include risk assessment, repositioning, keeping the skin moist and clean, debriding the wound as needed, applying dressings, ensuring adequate nutrition, teaching self-care, and consulting specialists if required. Progress will be monitored by assessing factors like skin integrity, wound characteristics, and drainage.
Nursing Diagnosis Impaired skin Integrity related to pressure, shearing forces, impaired circulation, and skeletal prominence as evidenced by presence of pressure ulcer Patient Goals 1. Maintains intact skin with no further pressure ulcer 2. Experiences healing of pressure ulcer Intervention Outcome Pressure Ulcer Prevention Tissue Integrity: Skin and Mucous membranes Use an established risk assessment tool to monitor Skin temperature……………….. individual’s risk factors (e.g., Braden Scale) to reduce Sensation…………………. or eliminate factors that contribute to development or Tissue Perfusion………………. progression of the pressure ulcer. Skin intactness………….. Remove excessive moisture on the skin resulting from perspiration wound drainage and fecal or urinary Measurement Scale incontinence to prevent maceration. 1= Severely compromised Avoid massaging over bony prominences to prevent 2= substantially compromised further tissue damage. 3= Moderately compromised Turn every one to two hours to avoid prolonged 4= Mildly compromised pressure in one area. 5= Not compromised Turn with care (e.g., avoid shearing) to prevent injury to fragile skin. Erythema………………. Position with pillows to elevate pressure points off the Blanching…………….. bed. Necrosis……………. Use specialty beds and mattresses as needed to provide pressure relief and increase circulation to the site. Measurement Scale Use devices on the bed (e.g., Sheepskin) that protect the 1= Severe individual from pressure. 2= Substantial Apply elbow and heel protectors as appropriate to avoid 3= Moderate pressure. 4= Mild Assist individual in maintaining a healthy way as the 5= None risk for pressure ulcer is increased in people who are obese or very thin.
Pressure Ulcer Care Wound Healing: Secondary Intention
Describe characteristic of the ulcer at regular intervals, Purulent Discharge……………….. including size (length x width x depth), stage (I to IV), Serous Drainage………………
NCP : Pressure Ulcer
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location, exudates, granulation, or necrotic tissue, and Serousanguineous Drainage……………….
epitelialization to provide baseline and ongoing data for Necrosis……………….. monitoring pressure ulcer. Sloughing…………….. Keep the ulcer moist to aid in healing. Tunneling………………. Cleanse the ulcer with the appropriate non-toxic solution, working in a circular motion from the center. Measurement Scale Debride ulcer, as needed, to promote new tissue growth. 1= Extensive Apply a permeable adhesive membrane, saline soaks, 2= Substantial ointments, and/or dressing, as appropriate, to promote 3= Moderate healing. 4= Limited Verify adequate caloric and high-quality protein intake 5= None to provide nutrients necessary for tissue repair. Teach individual or family member(s) wound care procedures to enhance self-care. Instruct family member/caregiver about science of skin breakdown to prevent recurrent. Initiate consultation services of the enterostomal therapy nurse, as needed, for specialized direction of ulcer care.