|
Subjective
Paitent complains of headache and back pain 6/10 that is constant, aching, and that
makes her not want to move about “anymore than she has too”.
Objective
Skin is warm, normal in color, except for areas of bruising on upper arms
Stage II ulcer noted on coccyx, 2x3 inches in size, 1 inch in depth, with clear,
non-odorous drainage, surrounding skin pink and is intact.
|
Problem
Impaired Skin Integrity
|
Long Term:
Client will regain integrity of skin surface
by the time of discharge.
|
Monitor the client's continence status, and minimize exposure of skin impairment
and other areas of moisture from incontinence, perspiration, or wound drainage.
EBN: Moisture from incontinence contributes to
pressure ulcer development by macerating the skin (WOCN, 2003).
Do not position the client on site of skin impairment. If consistent with overall
client management goals, turn and position the client at least every 2 hours. Transfer
the client with care to protect against the adverse effects of external mechanical
forces such as pressure, friction, and shear.
EditSelect a topical treatment that
will maintain a moist wound-healing environment and that is balanced with the need
to absorb exudate. EBN: Choose dressings that provide
a moist environment, keep periwound skin dry, and control exudate and eliminate
dead space (WOCN, 2003).
|
|
|
|
|
R/T
Mechanical Factors and immobilization
|
Short Term:
Client will
Editdescribe measures to protect
and heal the skin and to care for any skin lesion
|
Individualize plan according to the client's skin condition, needs, and preferences.
EBN: Avoid harsh cleansing agents, hot water, extreme
friction or force, or cleansing too frequently (Panel for the Prediction and Prevention of Pressure Ulcers
in Adults, 1992;
Wound, Ostomy, and Continence Nurses Society WOCN 2003).
Teach the client why a topical treatment has been selected. EBN:
The type of dressing needed may change over time as the wound heals and/or deteriorates
(WOCN, 2003).
EditIf consistent with overall client
management goals, teach how to turn and reposition at least every 2 hours. EB: If the goal of care is to keep a client (e.g., terminally
ill client) comfortable, turning and repositioning may not be appropriate (Krasner, Rodeheaver & Sibbald, 2001;
Panel for the Prediction and Prevention of Pressure Ulcers
in Adults, 1992).
|
|
|
|
|
AEB
Stage II ulcer noted on coccyx, 2x3 inches in size, 1 inch in depth, with clear,
non-odorous drainage, surrounding skin pink and is intact.
|