Assessment

Nursing
diagnosis

S:
O:

Impaired skin
integrity
related
to
pressure ulcer

(+) foot
ulcer @ L
foot
reddish
pink open
rupture
Dry and
shallow
wound
Stage II A partialthickness
loss of
skin
involving
epidermis
and
dermis.

Background of
the study

Planning

Intervention

ST:
After 6 to 8 hours
nursing intervention
the client will be
able to

Independent:

Have
reduced
further skin
impairment
of skin
integrity.

Assess between
folds of skin, use
a mirror to see
the heels. Also
assess under
oxygen tubing
especially on the
ears & the
cheek, and under
medical devices.

Patients
caregiver will
be able to
demonstrate
understandin
g and skills in
care of
wound

Note objective
data of pressure
ulcer (stage,
length, width,
depth, wound
bed appearance,
drainage &
condition of
periulcer tissue)

After 2 days
of nursing
intervention
the client will
be able to
reduced risk
for infection.

Increase the
frequency of
turning (turning
q2). Position the
client to stay off
the ulcer. If there
is no turning
surface without a

LT:

Rationale

Pressure ulcers
under medical
devices are
commonly
overlooked.

Reassessment of
ulcer is completed
each time dressing
are changed or
sooner if ulcer shows
manifestations of
deterioration.
Analyses of the
trends in healing are
important step in
assessment.
To disperse pressure
over time or
decreasing the
tissue load

Evaluation
ST:
After 6 to 8 hours
nursing
intervention the
client is able to
Have
reduced
further skin
impairment
of skin
integrity.
Patients
caregiver
will be able
to
demonstrate
understandi
ng and skills
in care of
wound
LT:
After 2 days of
nursing
intervention the
client is able to
reduced risk for
infection.

pressure ulcer,
use a pressure
redistribution
bed & continue
turning the client
Elevate heels off
the bed by using
pillows or heel
elevation botts.
Maintain head of
bed @ the lowest
elevation, if
client must have
the head
elevated to
prevent
aspiration,
reposition to 30
degree lateral
position. Use
seat cushions &
assess sacral
ulcers daily.
Follow body
substance
isolation
precautions; use
clean gloves &
clean dressing
for wound care.

Heel covers do not

relieve pressure, but
they can reduce
friction.
To prevent further
occurrence of
pressure ulcer.

To reduce risk of
infection

Practicing proper hand

washing before & after
wound care.

Dependent/Collabora
te:
Ensure adequate
dietary intake.
Review
dieticians
recommendation
s.
Prevent the ulcer
from being
exposed to urine
& feces. Use
indwelling
catheters, bowel
containment
systems, &
topical creams or
dressings.
Supplement the
diet with vitamins
& minerals.
Vitamins C and
zinc are
commonly
prescribed.

To prevent
malnutrition &
delayed healing
To prevent
contamination/sprea
d of infection

To promote wound
healing on clients
who do not have
adequate calories.
Pressure ulcers
cannot heal in clients
with severe
malnutrition.
To promote faster
healing & reduce
infection

Assessment

Nursing diagnosis

S:
O:

Impaired physical
mobility related
to neuromuscular
damage
involvement

slowed
movement
Limited

Planning
ST:

Nursing intervention
Monitor V/S

Rationale
To note

Evaluation
ST:

After 8 hours, of

changes and

After 8 hours, of

nursing intervention

for baseline

nursing intervention

the client will be

comparison.

the client is able to

able to shows

shows

range of

understanding

motion

situation or risk

diagnosis that

informed

situation or risk

factors and

contributes to

about the

factors and

individual treatment

immobility

situations

individual treatment

regimen and safety

that may

regimen and safety

measures

restrict

measures

(ROM)
Functional
level: level
2-requires
help from
another
person

Background
study

Determine the

movements

LT:
After 2 days of
nursing intervention

To be

Encourage

The longer

understanding

LT:
After 2 days of
nursing intervention

the client will be

and facilitate

the patient

the client will be

able to show

early

remains

able to show

,effective and

ambulation

immobile the

,effective and

collaborative

and other

greater the

collaborative

nursing

ADLs when

level of

nursing

interventions,

possible.

debilitation

interventions,

patient will

Assist with

that will

patient will

maintain position,

each initial

occur

maintain position,

function and skin

change:

function and skin

integrity

dangling,

integrity

sitting in chair,
ambulation
Perform

Exercise

passive or

promotes

active ROM

increased

exercises to

venous

all extremities

return,
prevents
stiffness, and
maintains
muscle
strength and
endurance

 Turn and

This

position every

optimizes

2 hours or as

circulation to

needed.

all tissues
and relieves
pressure.
To provide

Provide safety

safety and

measures(sid

reduce the

e rails, using

risk of

pillow to

pressure

support body

ulcers

part)

It provides
Massage back

comfort to

and bony

the patient

prominences

and
promotes
good
circulation

Independent
Consult with
physical or
occupational
therapist as
indicated

To develop
individual
exercise
therapy or
program