Nursing Care Plan

NU 310 NURSING CARE PLAN 2014

ASSESSMENT VALIDATION (10) Subjective “are you going to change me?” Objective Incontinent bowels, urine incontinence, muscle weakness. Nursing Dx (13) Risk for skin impaired skin integrity r/t to urinary/bowel incontinence. | PLANNING (15) LTG PT Skin and mucous membranes will be intact AEB: skin intactness/skin lesions not present/tissue perfusion/skin temperature. STG 1 PT will demonstrate understanding of personal risk factors for impaired skin integrity by end of shift 11/18/14 STG 2 PT will report altered sensation or pain at risk areas as soon as its identified by end of shift 11/18/14 | 4 Nursing INTERVENTIONS (12) 1. Teach the client skin assessment and ways to monitor for impending skin breakdown. 2. Inspect and monitor skin condition at least one day for color or texture changes, redness, localized heat, edema, pressure damage, or lesions. 3. Monitor the client’s continence status and minimize exposure of the site of skin impairment and other areas to moisture incontinence. 4. Monitor the clients skin care practices, noting types of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing. | 4 RATIONALES & 4 REFERENCES (12) 1. Basic elements of skin assessment are assessment of temperature, color, moisture, turgor, and intact skin (Ackley, 740). 2. Systematic inspection can identify problems early (Ackley, 739). 3. Implementing an incontinence prevention plan w/ the use of a skin protectant or a cleanser protectant can significantly decrease skin breakdown and pressure ulcer formation (Ackley, 739) Individualize plan according to the clients skin condition, needs, and preference (Ackley, 739). | EVALUATION of 3 GOALS(12) 1. The PT’s skin is currently...