Impaired Skin Integrity
Impaired Skin Integrity
(_)Actual (_) Potential
| (_) Burns of_______________________ (_) Decreased sensation (_) Immobility (_) Malnutrition (_) Pressure ulcer (_) Puritus (_) Stoma problems (_) Other:_____________________________ ____________________________________ ____________________________________ |
| Major: (Must be present) | (_) Disruption of epidermal and dermal tissue. |
| Minor: (May be present) | (_) Denuded skin. (_) Erythema. (_)Lesions. Other: |
| Date & Sign. | Plan and Outcome [Check those that apply] | Target Date: | Nursing Interventions [Check those that apply] | Date Achieved: |
| The patient will: (_)Maintain or develop clean and intact skin. (_) Other: | (_) Inspect and chart skin integrity q_____hrs. (_) Do wound care/dressing change as ordered. Describe:__________ (_) Provide measures to decrease pressure/irritation to skin:
(_) Turn and reposition q____hrs. (_) Up in chair for ___ minutes q____. (_) Gently massage bony prominences and pressure points with lotion q____. (_) Maintain adequate nutrition and hydration. (_) Change incontinent pad ASAP after voiding or defecation. (_) Expose skin to air if indicated. (_) Initiate health teaching and referrals as indicated. List:___________ (_) Keep nails short. (_) Mittens to decrease skin breakdown from scratching. (These are considered a restraint in some facilities. Get an order first.) (_) Change ostomy appliance prn when leaking. (_) Other:________________ |
__________________________
Patient/Significant other signature
__________________________
RN signature
Friday, May 16, 2008
|
Labels:
care plan
|
This entry was posted on Friday, May 16, 2008
and is filed under
care plan
.
You can follow any responses to this entry through
the RSS 2.0 feed.
You can leave a response,
or trackback from your own site.
1 comments:
I agree with you!
this would only serve as a guide.
http://nursingcareplanforpinoy.blogspot.com/
Post a Comment