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Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Short-term Independent:
Subjective Impaired Skin Objective • Assess • Pressure ulcers Short-term
Cues Integrity between folds under medical Objective
related to pressure After 6-8 hrs of of skin, remove devices are After 8 hrs of
injury secondary to nursing anti embolic commonly nursing
Objective prolonged interventions of stockings or overlooked. interventions
Cues immobility and nursing devices & use a patient:
unrelieved pressure interventions, the mirror to see the •reduced
• Grade 2 client will: heels. Also risk of
Pressure injury assess under further
on sacral • Have reduced oxygen tubing impairment
decubitus risk of further especially on of skin
impairment of the ears & the integrity as
• Dry & shallow skin integrity cheek, and evidenced
wound under medical by no actual
•Patient’s s/o will devices. additional
• Reddish-pink demonstrate tissue
open/rupture understanding & • Note objective • Reassessment of breakdown
blister skill in care of data of pressure ulcer is completed & no
wound ulcer (stage, each time persistent
• Dry Skin length, width, dressing are reddened
Long-term depth, wound changed or sooner areas
•Edema Objective bed appearance, if ulcer shows
After 3-4 days of drainage & manifestations of •patient’s
nursing condition of deterioration. s/o
interventions, the periulcer tissue) Analyses of the demonstrate
client will: trends in healing d
are important step understandin
• Experience in assessment. g & skill in
healing of care of
ulcer/regain skin •Increase the • To disperse wound
integrity (reduce frequency of pressure over
size of ulcer) turning time or PARTIALLY
(turning q2). decreasing the MET
• Reduce risk for Position the tissue load
infection client to stay Long-term
off the ulcer. If Objective
there is no After 4 days of
turning surface nursing
without a interventions
pressure ulcer, the client:
use a pressure
redistribution •Experience
bed & continue d healing of
turning the tissue as
client evidenced
•Elevate heels • Heel covers do development
off the bed by not relieve of
using pillows pressure, but they granulation
or heel can reduce tissue &
elevation botts. friction. decrease in
ulcer size.
•Maintain head • To prevent
of bed at the further •Reduce risk
lowest occurrence of of infection
elevation, if pressure ulcer. as evidenced
client must by
have the head observing
elevated to proper hand
prevent washing
aspiration, technique
reposition to 30 before &
degree lateral after wound
position. Use care.
seat cushions
& assess sacral PARTIALLY
ulcers daily. MET

•Follow body • To reduce risk

substance of infection
use clean
gloves & clean
dressing for
wound care.
proper hand
washing before
& after wound


• Prevent the ulcer • To prevent

from being contamination/spr
exposed to urine ead of infection
& feces. Use
catheters, bowel
systems, &
topical creams or

•Supplement the • To promote

diet with vitamins wound healing on
& minerals. clients who do
Vitamins C and not have adequate
zinc are calories.

•Provide oral • Pressure ulcers

supplementations, cannot heal in
tube-feedings or clients with
hyperalimentation severe
to achieve malnutrition.
positive nitrogen

devitalized tissue •To promote
from the wound faster healing &
bed, except in the reduce infection
avascular tissue
or on the heels.
Began by
cleansing the
ulcer bed with
normal saline,
then use
technique for
Once the ulcer is
free of devitalized
tissue, apply
dressing the keep
the wound bed
moist & the
surrounding skin
dry. Do not use
dressings on


• Ensure adequate •To prevent

dietary intake. malnutrition &
Review dietician’s delayed healing