Rodeoros, Yessamin Paith M.

NURSING CARE PLAN

SCIENTIFIC
CUES NSG DIAGNOSIS OBJECTIVE INTERVENTION RATIONALE EVALUATION
EXPLANATION

Subjective:  Impaired skin Impaired Tissue Short term: Independent NI:  Promotes  After 6-8 hrs of
integrity Integrity is defined as  At the end of 6-8 hrs. of  Encourage early circulation and nursing
“Hindi ako related to damage to mucous applying nursing ambulation/ reduces risks intervention the
makagalaw ng pressure sore membrane, intervention the client mobilization. associated with client will:
maayos dahil masakit due to corneal, integumentar will regain or improve immobility.  Regain the
at makati ang sugat extreme of age y, or subcutaneous ,the strength and  Provide protection strength and
ko.” As verbalized by and physical tissues. The skin is the movement of the by use of pads, movement of
 To increase
the patient. immobility as largest organ in the involved areas. pillows, foam the involved
circulation and
evidence by human body and is a mattress, water areas as
Objective: protective barrier. It  After 6-8 hrs. of alter/eliminate evidence by
drainage of bed, and so forth.
 Destruction of pus. protects the body applying nursing excessive tissue performing
skin layer. from heat, light, intervention the client  Use appropriate pressure. ROM exercise.
 Risk for injury, and infection. will be able to manifest barrier dressings,
 Destruction of infection Skin integrity relates signs of healing and wound coverings,  To protect the  Reduced risk of
skin layer. related to to skin health. A skin reduction of pressure drainage wound and/or impairment of
pressure sore integrity problem ulcer. appliances, and surrounding skin integrity as
 Pain upon as evidence by might indicate the skin-protective tissues. evidenced by
movement. elevated body skin is damaged, Long term: agents for no actual
temperature exposed to injury or  After 3-5 days of open/draining  A good diet with additional
 Drainage on and foul odor inefficient to repair applying nursing wounds and tissue
nutritional foods
the pus. on the and recover normally. intervention the client stomas. breakdown.
and vitamins may
pressure sore. The key marker of will verbalize the wound
 Foul odor on quality care is the is decreases in size and Dependent NI: help promote  After 3-5 days of
the pressure  Impaired bed maintenance of skin has increased  Assess patient’s wound healing. nursing intervention
sore mobility integrity and granulation tissue.j nutritional status; the client will:
related to prevention of refer to nutritional  To assist with  Experienced
 Vital Sign: extreme of age pressure ulcers. With  After 2-3 days of consultation. developing plan of healing of
 BP: 140/90 as evidence by this, the nurse must applying nursing care for tissue.
 T: 38 insufficient be aware of intervention the client  Consult with problematic or
 HR: 87 muscle identifying at-risk will able to verbalize wound specialist potentially serious  Describes
 R: 15 strength. individuals and the feelings of increased as indicated. wounds. measures to
myriad factors that self-esteem and ability protect and
place patients at risk to manage situation.  Obtain specimen  To determine heal the tissue
for skin damage. from draining appropriate and prevent
 After 2-3 days of 'm wounds when therapy. injury.
Reference: Wayne, nursing intervention the appropriate for
RN, G. (2019). Risk for client will be able to culture/sensitivitie  Demonstrates
Impaired Skin participate in s/ Gram’s stain. understanding
Integrity – Nursing prevention measures of plan to heal
Diagnosis Guide. and treatment program. tissue and
[online] prevent injury.
 Rodeoros, Yessamin Paith M.

EXTRINSIC FACTORS: Pressure Ulcers

INTRINSIC FACTORS:
 Undue and prolonged pressure
 Shear and friction  Altered consciousness
STAGES PATHOGENESIS SYMPTOMS
 Moisture  Absent sensation
 Abnormal posture  Age related changes
 Impaired Immobility Prolonged Unusual changes in skin  Emotional stress
STAGE 1
pressure/friction/shear color or texture  Cardiovascular changes
Nonblanchable erythema
signaling potential An area of skin that
ulceration. Blood flow in the skin
feels cooler or warmer
ceases once external
to the touch than other
pressure more than 30 mm
areas
Hg.
Swelling
STAGE 2

Partial thickness skin loss

Tissue hypoxia
involving the epidermis and Pus-like draining
CLINICAL FEATURES: possibly the dermis.
Tender areas
Skin appears re, may be Ulceration pressure sores
tender,painful,firm,soft cool
or warm than surrounding. STAGE 3

Full-thickness skin loss CLINICAL FEATURES:

involving damage of
Wound may be shallow and
subcutaneous tissue that
pinkish or red, looks like
may extend down.
fluid blisters or ruptured
blisters.

STAGE 4

Full thickness skin loss with

CLINICAL FEATURES:
Loss of skin, unusually
exposes some fat, ccrater
like. Bottom of thethe
wound may have some
yellowush dead tissue
tissue necrosis or damage to
muscle, bone, or supporting CLINICAL FEATURES:
structures, such us a tendon
The wound may expose
or joint capsule.
muscle, bone or tendons.
Bottom of the wound likely
contains dead tissue that is
yellowish or dark ang crusty.