Cabacub, Paul John BSN407/ Group 25

NURSING CARE PLAN

Cues and Data Objective: Nursing Diagnosis Analysis
Pressure ulcers (pressure sores) continue to be a common health problem, particularly among the physically limited or bedridden elderly. The problem exists within the entire health framework, including hospitals, clinics, long-term care facilities and private homes. For many elderly patients, pressure ulcers may become chronic for no apparent reason and remain so for prolonged periods, even for the remainder of the patient's lifetime. A large number of

Goal and objectives After 20 mins of discussion, the patient and relative will gain enough knowledge regarding the contributing factors of pressure ulcer and ways to prevent it.

Interventions
Independent:

Rationale

Evaluation After 20 mins of nursing interventions, the patient and relative was able to verbalize understanding of the contributing factors of pressure ulcer and ways to prevent it.

Risk for Impaired -Body skin weakness integrity related to -An area on body the patients weakness buttocks (Temporary was immobility) reddened
and warm to touch. -Relative ask for nursing stuff help to reposition patient.

Educate patient and relative on the importan ce of proper dieting and food intake. Educate the pt on the importan ce of keeping the skin clean and dry.

Nutrition is fundamen tal to normal cellular integrity and tissue repair. (Potter and Perry, 2008, p. 1310) Moisture softens the skin and causes a break in the skin integrity. (Potter & Perry,

After 10 mins of demostratio n the

Teach

After 10 mins of demonstration

grade 3 and 4 pressure ulcers become chronic wounds, and the afflicted patient may even die from an ulcer complication (sepsis or osteomyelitis). The presence of a pressure ulcer constitutes a geriatric syndrome consisting of multifactorial pathological conditions. The accumulated effects of impairment due to immobility, nutritional deficiency and chronic diseases involving multiple systems predispose the aging skin of the elderly person to increasing vulnerability.

relative will be able to know the proper turning and positioning of the patient.

relative proper repositio n of patient and reposito n pt at least once every two hours.

2009, p. 1302) Positionin g interventi ons reduce pressure and shearing force to the skin. (Potter & Perry, 2009, p. 1305) Moisture softens the skin and causes a break in the skin integrity. (Potter & Perry, 2009, p. 1302) Systemati c

the relative was able to properly turned and positioned the patient.

Keep the skin clean and dry

Monitor

skin conditio n at least once a day for color or

texture changes, dermatol ogical conditio ns, or lesions.

Passive

inspectio n can identify impendin g problems early. (Ackley & Ladwig, 2008, p. 754)

Range of motion exercise

This promote proper blood circulatio n