eNursing Care Plan 23-1
Patient with Chronic Skin Lesions
Nursing Diagnosis*
Risk for Infection
Risk factors: Open lesions, presence of environmental pathogens
Patient Goals
1. Has no infection of lesions
2. Maintains localization of lesions
Outcomes (NOC)
Risk Control: Infectious
Process
 Identifies infection risk in
daily activities ___
 Monitors environment for
factors associated with
infection risk ___
 Maintains a clean environment
___
 Practices hand hygiene ___
 Practices infection control
strategies ___
 Monitors changes in general
health status ___
Measurement Scale
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated
Tissue Integrity: Skin and
Mucous Membranes
 Skin lesions ___
 Erythema ___
 Induration ___
 Necrosis ___
Measurement Scale
1 = Severe
*Nursing diagnoses listed in order of priority.
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Interventions (NIC) and Rationales
Infection Protection
 Inspect skin and mucous membranes for redness,
extreme warmth, or drainage to promote early
detection and treatment of infection.
 Teach patient and caregivers about signs and
symptoms of infection and when to report them to
the health care provider to provide ongoing care.
 Teach patient and caregiver how to avoid infections
to prevent infections and potential transmission.
Skin Surveillance
 Observe extremities for color, warmth, swelling,
pulses, texture, edema, and ulcerations to promote
early identification and treatment.
 Institute measures (e.g., overlay mattress,
repositioning schedule) to prevent further
deterioration.
 Document skin or mucous membrane changes to
evaluate effectiveness of therapy.
Skin Care: Topical Treatments
 Dress patient in nonrestrictive clothing to decrease
irritation.
 Clean skin with antibacterial soap, as appropriate, to
reduce environmental pathogens.
 Apply emollients, topical antibiotics, and topical
antiinflammatory agents to the affected area (as
appropriate) to decrease inflammatory response and
treat infection.
 Add moisture to environment with a humidifier, as
needed, to prevent drying and skin cracking.
eNursing Care Plan 23-2

2 = Substantial
3 = Moderate
4 = Mild
5 = None

Nursing Diagnosis
Lack of Knowledge
Etiology: Lack of information about disease process, management plan, prevention of
scarring, use of over-the-counter (OTC) medications
Supporting data: Questions about self-care

Patient Goal
Describes the disease process and management plan for chronic skin lesions
Outcomes (NOC)
Knowledge: Treatment
Regimen
 Specific disease process ___
 Benefits of treatment ___
 Self-care responsibilities for
ongoing treatment ___
 Expected effects of treatment
___
 Prescribed medication regimen
___
 Benefits of disease
management ___
Measurement Scale
1 = No knowledge
2 = Limited knowledge
3 = Moderate knowledge
4 = Substantial knowledge
5 = Extensive knowledge
Interventions (NIC) and Rationales
Teaching: Disease Process
 Assess the patient’s current level of knowledge
related to specific disease process to determine
learning needs.
 Describe the disease process to provide information
needed for self-care.
 Discuss therapy/treatment options to promote
involvement in treatment.
 Describe reason behind management/
therapy/treatment recommendations to increase
compliance.
 Teach the patient treatment measures to
control/minimize symptoms.
Teaching: Prescribed Medication
 Teach the patient the purpose and action of each
medication to promote self-care.
 Teach patient about possible adverse effects of each
medication.
 Teach the patient the proper
administration/application of each medication to
promote self-care
 Evaluate the patient’s ability to self-administer
medications to determine if learning needs are met.

Copyright © 2020 by Elsevier, Inc. All rights reserved.

eNursing Care Plan 23-3

Nursing Diagnosis
Disturbed Body Image
Etiology: Changes in physical appearance, poor self-image, fear of rejection, lack of
knowledge about cover-up techniques
Supporting data: Lack of social activities, seeking to be alone, expression of feelings of
rejection

Patient Goals
1. Increases social interaction with family members and close friends
2. Expresses a sense of increased self-image with use of enhancement techniques

Outcomes (NOC) Interventions (NIC) and Rationales

Body Image
 Congruence between body
reality, body ideal, and body
presentation ___
 Adjustment to changes in
physical appearance ___
 Satisfaction with body
appearance ___
Measurement Scale
1 = Never positive
2 = Rarely positive
3 = Sometimes positive
4 = Often positive
5 = Consistently positive
Social Involvement
 Interacts with close friends
___
 Interacts with family members
___
 Participates in organized
activity ___
 Participates in leisure activities  Facilitate patient input and planning of future
with others ___
Measurement Scale
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated
Body Image Enhancement
 Assist patient to discuss changes caused by illness or
surgery to identify patient’s response.
 Assist patient to separate physical appearance from
feelings of personal worth to foster sense of support.
 Identify means of reducing the impact of any
disfigurement through clothing, wigs, or cosmetics
to enhance body image.
 Assist patient to identify measures that will enhance
appearance.
 Identify support groups available to patient to
provide long-term adjustment.
Socialization Enhancement
 Encourage enhanced involvement in already
established relationships to use support of known
others.
 Encourage social and community activities to
increase socialization.
 Give feedback about improvement in care of
personal appearance or other activities to provide
positive support.
activities to provide support during increased
socialization.

Copyright © 2020 by Elsevier, Inc. All rights reserved.