Impaired Skin Integrity

Published on Saturday March 10th , 2007

Impaired Skin Integrity

(_)Actual (_) Potential

Related To:
[Check those that apply]

(_) Burns of_______________________ (_) Decreased sensation (_) Immobility (_) Malnutrition (_) Pressure ulcer (_) Puritus (_) Stoma problems (_) Other:_____________________________ ____________________________________ ____________________________________

As evidenced by:
[Check those that apply]

Major: (_) Disruption of epidermal and dermal tissue. (Must be present) Minor: (_) Denuded skin. (May be present) (_) 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: y y y y

fleece pad egg crate mattress keep skin clean and dry other:

(_) 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

Impaired Physical Mobility

Published on Saturday March 10th , 2007

Impaired Physical Mobility

(_)Actual (_) Potential

Related To:
[Check those that apply]

(_) Amputation (_) Cardiovascular (_) External devices (_) Impaired balance (_) Limited ROM (_) Musculoskeletal impairment

(_) Neuromuscular impairment (_) Pain (_) Surgical procedure (_) Trauma (_) Other:_____________________________ ____________________________________ ____________________________________

As evidenced by:
[Check those that apply]

Major: (Must be present)

(_) Inability to move purposefully within the environment, including bed mobility, transfers, and ambulation.

Minor: (_) Range of motion limitations. (May be present) (_) Limited muscle strength or control. (_) Impaired coordination.

Date & Sign.

Plan and Outcome

[Check those that apply]

Target Date:

Nursing Interventions
[Check those that apply]

Date Achieved:

The patient will: (_) Maintain or increase strength and endurance of upper/lower limbs A.E.B.:

(_) Assess symmetry, strength, and degree of mobility. (_) Passive/active ROM exercises as ordered by physician q_____ to:__________(body part). (_) Position in proper alignment and

(_) Will not develop complications of

immobility. (_) Demonstrate use of adaptive device(s) to increase mobility. Device:

resposition q____ hrs. (_) Encourage isometric exercises when indicated. (_) Up in chair _____ minutes q____. (_) Check/teach proper use/function of adaptive equipment. (_) Provide progressive mobilization. (_) Referral: y y y PT OT other:

(_) Other:

(_) Other:________________ ________________________ ________________________ ________________________

__________________________ Patient/Significant other signature

__________________________ RN signature

NCP Nursing Care Plans for Burns Injury. A major burn is a devastating injury, requiring painful treatment and a long period of rehabilitation. Burns have a catastrophic effect on people in terms of human life, suffering, disability, and financial loss. Burns can be fatal, permanently disfiguring, and incapacitating, both emotionally and physically. Infections are a major cause of morbidity and mortality in seriously burned patients. The skin injury from burns has six different mechanisms of injury: scalds, contact burns, fire, chemical, electrical, and radiation. Causes for Burns Injury Thermal burns, the most common type, result from preventable accidents occur because of fires from motor vehicle crashes, accidents in residences, and arson or electrical malfunctions. Chemical burns result from the contact, ingestion, inhalation, or injection of acids, alkali, or vesicants. Electrical burns commonly occur after contact with faulty electrical wiring or high-

voltage power lines. Friction, or abrasion, burns happen when the skin is rubbed harshly against a coarse surface. Sunburn follows excessive exposure to sunlight and improper use of tanning lights. Complications for Burns Injury Leading causes of death in burn patients are respiratory complications and sepsis. Other possible complications include:

y y y y

Hypovolemic shock Anemia Malnutrition Multisystem organ dysfunction.

Nursing Assessment Nursing Care Plans for Burns Injury Patient history. Obtain a complete description of the burn injury, including the time, the situation, the burning agent, and the actions of witnesses. The time of injury is extremely important since any delay in treatment may result in a minor or moderate burn becoming a major injury. Elicit specific information about the location of the accident, since closed-space injuries are related to smoke inhalation. If abuse is suspected, obtain a more in-depth history from a variety of people who are involved with the child. The injury may be suspect if there is a delay in seeking health care, if there are burns that are not consistent with the story, or if there are bruises at different stages of healing. Note whether the description of the injury changes or differs among family or household members. Basic assessment of airway, breathing, and circulation (ABCs) takes first priority. Once the ABCs are stabilized, perform a complete examination of the burn wound to determine burn severity. First, determine the depth of tissue damage. A partial-thickness burn damages the epidermis and part of the dermis; a full-thickness burn also affects the subcutaneous tissue. The more traditional method is to gauge burns by degree. Most burns include a combination of degrees and thicknesses

RULE OF NINES The rule of nines is a practical technique used to estimate the extent of TBSA total body surface area involved in a burn. The technique divides the major anatomic areas of the body into percentages: in adults, 9% of the TBSA is the head and neck, 9% is each upper extremity, 18% is each anterior and posterior portions of the trunk, 18% is each lower extremity, and 1% is the perineum and genitalia. Clinicians use the patients palm area to represent approximately 1% of TBSA. Serial assessments of wound healing determine the patients response to treatment. Ongoing monitoring throughout the acute and rehabilitative phases is essential for the burn patient. Fluid balance, daily weights, vital signs, and intake and outpu Nursing diagnosis Nursing Care Plans for Burns Injury

y y y y y y y y y y y

Impaired gas exchange Ineffective airway clearance Acute pain Decreased cardiac output Deficient fluid volume Ineffective tissue perfusion: Peripheral Hypothermia Impaired skin integrity Impaired physical mobility Disturbed body image Risk for infection

Nursing outcomes Nursing Care Plans for Burns Injury Nursing Key outcomes Nursing Care Plans for Burns Injury, Patient will:

y y y y y y y y y y y y y y y

Ventilation will remain adequate. Airway will remain patent Achieve pain relief with analgesia or other measures. Maintain adequate cardiac output. Fluid volume will remain within the acceptable range. Exhibit signs of adequate peripheral perfusion Communicate understanding of special dietary needs. Maintain normal body temperature. Wounds and incisions will appear clean, pink, and free of purulent drainage. Attain the highest degree of mobility possible within the confines of the injury. Express positive feelings about self. Express that he feels less anxious. Demonstrate effective coping mechanisms. Remain free from signs and symptoms of infection. Express his feelings and fears about the traumatic event.

Nursing interventions Nursing Care Plans for Burns Injury

y y

y y

Provide immediate, aggressive burn treatment to increase the patient's chance for survival. Airway management; Anxiety reduction; Oxygen therapy; Airway suctioning; Airway insertion and stabilization; Cough enhancement; Mechanical ventilation; Positioning; Respiratory monitoring Airway Management Facilitation of patency of air passages Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient. Analgesic Administration Use of pharmacologic agents to reduce or eliminate pain. Environmental Management Manipulation of the patients surroundings for promotion of optimal comfort Hemodynamic Regulation Optimization of heart rate, preload, afterload, and contractility. Circulatory Care Mechanical Assist Devices: Temporary support of the circulation through the use of mechanical devices or pumps Fluid Management Promotion of fluid balance and prevention of complications resulting from abnormal or undesired fluid levels. Hypovolemia Management Reduction in extracellular and/or intracellular fluid volume. Shock Management: Volume: Promotion of adequate tissue perfusion for a patient with severely compromised intravascular volume. Fluid/Electrolyte Management Promotion of fluid/electrolyte balance and prevention of complications resulting from abnormal or undesired fluid/serum electrolyte levels. Circulatory Care Arterial/Venous Insufficiency: Promotion of arterial/venous circulation Hypothermia Treatment Rewarming and surveillance of a patient whose core body temperature is below 35C. Temperature Regulation: Attaining and/or maintaining body temperature within a normal range

y y

Wound Care Prevention of wound complications and promotion of wound healing Exercise Therapy Use of active or passive body movement to maintain or restore flexibility; use of specific activity or exercise protocols to enhance or restore controlled body movement Body Image Enhancement improving a patients conscious and unconscious perceptions and attitudes toward his/her body. Self Esteem Enhancement Assisting a patient to increase his/her personal judgment of self worth. Infection Protection Prevention and early detection of infection in a patient at risk. Infection Control Minimizing the acquisition and transmission of infectious agents. Surveillance: Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making