| PLAN |
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- As appropriate, educate the patient/family to change the patient's position every two hours, the importance of keeping the skin clean and dry, the importance of adequate food and fluid intake, and the procedure for dressing changes/skin care.
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- Assess the skin on admission and at each shift.
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- Collaborate with interdisciplinary team members, as needed.
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- Document history of skin breakdown.
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- Keep the skin clean and dry. Use barrier ointments to protect skin.
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- Other:
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- Perform wound treatments, as ordered. Document the wound size, appearance, amount of drainage, and the wound care treatments performed.
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- Reposition patient every two hours and PRN, preventing sheering and protecting bony prominences from pressure.
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| DESIRED OUTCOME |
Damage to the epidermal and dermal tissue. For example cellulitis,
1 NANDA International (2005). Nursing Diagnoses: Definitions &
Classification 2005-2006. Philadelphia: Author.
2Carpenito, L. J. (2000). Nursing Diagnosis: Application to Clinical
Practice (8th ed.). Philadelphia: Lippincott
3Wilkinson, J. M. (2005) Nursing diagnosis handbook (8th ed). Upper
Saddle River, NJ: Prentice Hall.
venous stasis changes, falls and other injury, and Stage I, II, and III
pressure sores. (For Stage IV Pressure Sores or surgical incisions see
Tissue Integrity, Impaired.) 1, 2
Related To: Bacterial, viral, or fungal infections, diabetes, nutritional
alterations, mechanical irritants, treatment related injury (restraints,
NGT, traction), excretions, noxious chemical agents. 1, 2
References:
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