Nursing care plan for impaired skin integrity (including diagnosis): The nursing care plan template below includes the following conditions: Impaired Skin Integrity, Risk for Skin Breakdown, Altered Skin Integrity, and Risk for Pressure Ulcers.
What are nursing care plans? How do you develop a nursing care plan? What nursing care plan book do you recommend helping you develop a nursing care plan?
This care plan is listed to give an example of how a Nurse (LPN or RN) may plan to treat a patient with those conditions.
Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. Do not treat a patient based on this care plan.
Care Plans are often developed in different formats. The formatting isn’t always important, and care plan formatting may vary among different nursing schools or medical jobs. Some hospitals may have the information displayed in digital format, or use pre-made templates. The most important part of the care plan is the content, as that is the foundation on which you will base your care.
Nursing Care Plan for: Impaired Skin Integrity, Risk for Skin Breakdown, Altered Skin Integrity, and Risk for Pressure Ulcers.
If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, scroll down to view this completed care plan.
Scenario: |
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An 93 year old female presents to the ER with her family. The patient looks very thin and malnourished. Pt’s weight is 95 lb and height is 5′ 6. Pt has advance stage of Alzheimer’s and is aphasic. Pt is also a type 1 Diabetic. Contractures are noted in both upper extremities. The family states the patient has been unable to walk for the past year which has lead to her being bed ridden and has not be able to eat for the past week. On assessment, you note that the patient has a stage 3 pressure ulcer on her right heel and sacral area. The wound on the heel is draining purulent yellow drainage and is 3 inches wide and 1 1/2 inches deep. The sacral wound is 5 inches wide and 2 inches deep with no drainage noted. Pt VS: HR 80, BP 120/80, O2 Sat 98% on RA, and RR 15. Pt takes the following medications: Lisinopril 12.5 mg PO Daily, ASA 81mg PO Daily, Regular Insulin per sliding scale with meals, Lantus 30 units Subq at night. Lab and Diagnostic work shows: WBC 22, Blood Sugar 126.
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Nursing Diagnosis: |
| Impaired Skin Integrity related to malnutrition and pressure ulcers as evidence by disruption of epidermal and dermal tissues. |
Subjective Data: |
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Unable to walk for the past year and has not be able to eat for the past week.
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Objective Data: |
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Pt’s weight is 95 lb and height is 5′ 6. Pt has advance stage of Alzheimer’s and is aphasic. Pt is also a type 1 Diabetic. Contractures are note in both upper extremities. stage 3 pressure ulcer on her right heel and sacral area. The wound on the heel is draining purulent yellow drainage and is 3 inches wide and 1 1/2 inches deep. The sacral wound is 5 inches wide and 2 inches deep with no drainage noted. Pt VS: HR 80, BP 120/80, O2 Sat 98% on RA, and RR 15. Pt takes the following medications: Lisinopril 12.5 mg PO Daily, ASA 81mg PO Daily, Regular Insulin per sliding scale with meals, Lantus 30 units Subq at night. Lab and Diagnostic work shows: WBC 22, Blood Sugar 126.
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Nursing Outcomes: |
| -Pt will not have any further skin breakdown during the hospitalization.-Pt’s wounds will be kept clean and free from any further infection.
-Pt will gain at least 3 lbs by discharge. -Pt family will verbalize 2 ways on how to prevent pressure ulcers. |
Nursing Interventions: |
| -Pt will be turned every two hours as evidence by nursing documentation.-Pt’s wounds will be changed daily per wound care orders and proper hand hygiene will be performed before and after dressing changes.
-Pt will be started on TPN per MD order and will be weighed every day. -The nurse will verbalize and demonstrate to the pt’s family 4 ways on how to prevent pressure ulcers. |