Assessment

6 items
Subjective
&/or
Objective
Designate
with
S or O

NANDA 3 part
Nursing Diagnosis
related to As
Evidence by

1. S
I prefer to
stay in the
wheelchair to
watch my
soap opera

NANDA 3 part
nursing diagnosis:

2. O
Skin color
pallor

3. S
I like to be
moved
frequently

4. S
When I go to
the restroom I
am having
trouble on
drying myself
well

STG
LTG

Impaired skin
integrity r/t
immobility and
decreased
circulation AEB
disruption of skin
surface

Plan with brief

rationale for each one
9 individual plans
(3) Assessment
(3) activity
(3) action
Number them!
1. Use pressure
reduction surface for
wheelchair seating.
Prolonged sitting in
wheelchair exposes the
person to a high risk of
decubitus ulcer.

2. Monitor bony
prominences and
include areas
occipital, sacrum,
greater trochanter,
malleoli of signs of
skin breakdown.

This action will help to

prevent a decubitus ulcer.

STG: Skin to
remain intact
without evidence
of breakdown
rash, infection or
pruritus.

LTG: Incision to
remain well and

3. Use lift draw sheet

to prevent friction
while moving patient
in bed.
Friction forces produce
shear stresses and strains
within the skin and
underlying tissue.

4. Keep skin free of

urine and feces with
cleansing
immediately after
incontinence or
soiling.

Moisture causes the skin to

lose the dry outer layer and

Interventions
Correlates with
plan
Put here what was
done
Number them!

Evaluation
Correlate with
interventions
Number them!

1. Used a chair
cushion and foam
wedges to prevent
pressure injury

1.

2. Assessed
occipital, sacrum,
greater trochanter,
malleoli for any
signs of skin
breakdown

2.

3. Used a lift draw

sheet to move the
patient in bed.

4. Encouraged the
patient to keep the
skin free of urine
and feces and
immediately report
if an accident
happens.

5. Used positioning
devices to cushion

3.

4.

5.

6.

5. S
I think I need
more cushion
when I sit on
the
wheelchair

6. S
I want to
learn how to
take care of
my skin

without signs and

symptoms of
infection

reduces the tolerance of

the skin for pressure and
shear.

5. Use positioning
devices to cushion
bony prominences.

Cushion helps to mitigate

the average pressure
concentrated in bony
prominences.

6. Educate the patient

regarding skin care.
To prevent skin breakdown

7. Apply moisture
barriers and
absorptive products
to keep moisture
away from skin.

This action will help to keep

dry the outer layer of the
skin.

8. Provide and
monitor fluid intake.
Optimizing nutritional
status is needed to
promote wound healing.

9. Dressing change
and wound care daily
per physicians order.

This will help to heal wound

faster and to prevent
infection.

bony prominences
6. Patient educated
about skin and
wound assessment
and ways to
monitor signs and
symptoms of
infection.
7. Moisture barriers
and absorptive
products applied to
keep moisture away
from skin
8. Input and output
recorded.
9. Wound care
provided and
patient taught
about how to care
of the wound

7.

8.

9.