NCP # 2 (Actual) IMPAIRED SKIN INTEGRITY

Assessment Cues Nursing Pathophysiology Planning Desired Intervention Rationale Evaluation

Diagnosis Outcome

Subjective Cues: Impaired Skin Pott’s Disease After 8 hrs of Nursing After 8 hours of
Integrity R/T intervention the client nursing intervention
Patient expresses Physical Requires bed rest will be able to: the client was able to:
pain by pointing at Immobility AEB
his lower back. Disruption of skin Patient is • Display timely Assess dimensions and depth To establish comparative Goal not met- the
surface immobile for long healing of skin in centimeters; exudates— baseline/evaluate wound did not heal
Objective Cues: (epidermis) periods of time. lesions/ color, odor, and amount; effectiveness of and it even got
wounds/pressure margins—fixed or unfixed; interventions. bigger.
Disruption of skin Pressure on the sores without tunneling/tracts; evidence of
surface(epidermis) lower back. complication. necrosis or healing.

Destruction of skin Inadequate supply • Maintain Provide adequate nutrition to To improve tissue Goal met- patient was
layers (dermis) of oxygen to the optimal nutrition. the client. regeneration. able to consume the
area. special diet prepared
Facial Grimacing for him.
Skin Tissue is • Prevent further Reposition from time-to- To reduce stress on
damaged. worsening of time/periodic weight shifts. pressure points, improve Goal met- patient was
wounds and spread Protect bony prominences with blood flow to tissues, and turned periodically
Impaired skin of infection. pillows or pads. promotes healing. and wounds were
integrity properly dressed.
Dressing of pressure ulcer. To reduce bacterial
contamination and
promote healing.
Encourage client to participate Goal Met- patient
• Participate in in the treatment regimen by To gain the patients’ asked to be turned to
preventive measures explaining procedures and cooperation. apply mediation on
and treatment interventions done. his lower back.
program.
Collaborative: To facilitate faster wound
Apply/Administer topical healing and prevent
drugs as indicated. further infection.