NURSING CARE PLAN

NURSING
CUES OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Impaired skin After 8 hours of applying

Objective: integrity interventions, the bed
sore manifested by the  Determine client’s health
>Bed sore grade 1 patient will lessened. status.  Client’s conditions
>Swelling on Right  Determined nutritional may trigger bed sores.
arm and leg status and potential for  To determine
>Skin rashes on her delayed healing or tissue causative factors
foot injury  To check status for
 Assess skin and noted for hydration
Initial vital signs taken: skin turgor and sensation  To prevent further
 Instruct SO of the patient complications
Bp= 160/90  To reduce
Temp=36.3 to reposition pt every hour
RR= 21  Maintain strict hygiene transmission of
Spo2= 90  Massage bony microorganisms
prominences and avoid  To prevent
friction when moving complication of bed
patient sores
 Provide protection by use  To increase circulation
of pads, pillows, foam and alter/eliminate
mattress,, water bed excessive tissue
 Observe for pressure
reddened/blanched areas  Reduces likelihood of
and institute treatment progression to skin
immediately. breakdown
 Provide for safety  For safety purposes
measures during  For regular
ambulation and other observation and to
therapies. support over all
 Provide information to assessment
patient/SO about the  To decrease irritable
importance of regular itching
observation and effective
 skin care in preventing  To maintain general
problems. and good health and
 Suggest use of ice, and skin turgor.
lotions
 Emphasize importance of
adequate nutritional/ fluid
intake