XI.

NURSING CARE PLAN AND HEALTH TEACHING PLAN

NURSING CARE PLAN (1)
NURSING DIAGNOSIS CUES Impaired Skin Integrity related to decubitus ulcer stage I and IV as manifested by destruction of skin layers Subjective(by the relative) nakahiga lang sya lagi sa bahay nanunuod ng t.v. o kaya nakikinig ng radyo. dati ang lalakilaki talaga nung sugat nya sa likod tapos may mga itim-itim pa, mas maayos na nga yung sugat nya sa likod ngayon kaysa dati. ANALYSIS The skin is a barrier to infectious agents; however, any break in the skin can readily serve as a portal of entry putting the individual at risk for potential infections. (Fundamentals of Nursing by Kozier, et.al., 7th edition ,page 633) GOAL / OBJECTIVES GOAL After 8 days of nursing intervention, the client will be able to display timely healing pressure sores without complications. OBJECTIVES After 8 days of nursing interventions, patients stage I decubitus ulcer will not have any increase in redness or any skin tears and patients stage IV decubitus ulcer wound will decreased in size and minimize presence of wound. NURSING INTERVENTIONS Independent RATIONALE EVALUATION

Periodically

remeasure wound and observe for complications

To monitor progress Wounds were

of wound healing

remeasured and observed for complications.

Assess skin. Note the skin color, turgor, and sensation. Describe and measure the decubitus ulcer and wounds and observe changes.

Establishes

comparative baseline providing opportunity for timely intervention.

The skin was

assessed. The skin color, turgor and sensations were noted. Observed changes, measured, and described the patients decubitus ulcer and wounds

Objective Presence of decubitus ulcer stage I in left scapula 4 cm in diameter and stage IV in sacrum 9 cm in diameter Physical immobilization

Reposition the

patient every 2 hours and avoid repositioning the patient on site of the decubitus ulcer

Repositioning improves blood circulation and reduces pressure on bony prominences.

The patient was repositioned every 2 hours, avoiding the patients site of decubitus ulcer

Monitor temperature

An increase in

Temperature

was monitored

temperature can be a sign of infection.

Localized erythema around the decubitus ulcer Hemiplegia Hemiparesis Facial Grimace of pain

Assess patient's nutritional status.

Inadequate

Inter-dependent Keep the area clean and dry, carefully dress wounds, prevent infection and stimulate circulation to the surrounding areas

nutritional intake places individuals at risk for skin breakdown and compromises healing.

Patient's nutritional status was assessed.

Keeping the area clean and dry will prevent harbor of pathogenic microorganisms thus prevents further infection.

Area kept clean and dry with wound dressing applied carefully. Prevented infection and stimulated circulation to the surrounding areas. Wet and wrinkled linens were removed

Remove wet/wrinkled linens promptly

Moisture potentiates skin breakdown

Instruct patient to

avoid scratching the decubitus ulcer. Scratching may lead to skin breakdown which may result to lesion or wound.

Instructed patient to avoid scratching the decubitus ulcer.

Dependent

Administer topical medications as prescribed.

Prescribed medications administered

To protect the wound and the surrounding tissues

HEALTH TEACHING PLAN (1)

LEARNING OBJECTIVES Goal (this plan is directed to the clients relative due to the clients inability to comprehend) After 8 days of nursing intervention, the client will be able to display timely healing pressure sores without complications. Objectives After 8 days of nursing interventions, patients stage I decubitus ulcer will not have any increase in redness or any skin tears and patients stage IV decubitus ulcer wound will decreased in size and minimize presence of wound. Bedsores, more accurately called pressure sores or pressure ulcers, are areas of damaged skin and tissue that develop when sustained pressure cuts off circulation to vulnerable parts of your body, especially the skin on your buttocks, hips and heels. Without adequate blood flow, the affected tissue dies. Stage I. A pressure sore begins as a persistent area of red skin that may itch or hurt and feel warm and spongy or firm to the touch. In blacks, Hispanics and other people with darker skin, the mark may appear to have a blue or purple cast, or look flaky or ashen. Stage I wounds are superficial and go away shortly after the pressure is relieved. Stage II. At this stage, some skin loss has already occurred either in the outermost layer of skin (the epidermis), the skin's deeper layer (the dermis), or in both. The wound is now an open sore that looks like a blister or an abrasion, and the surrounding tissues may show red or purple discoloration. Stage III. By the time a pressure ulcer reaches this stage, the damage has extended to the tissue below the skin, creating a deep, crater-like wound. Stage IV. This is the most serious and Develop therapeutic nurse-client relationship. Promotes trust, provides atmosphere in which client is most successful when conducted in a positive, nonjudgmen tal atmosphere Time: 30minutes Venue: ward Resources: visual aids The client was able to display timely healing pressure sore without complications LEARNING CONTENT METHOD/ STRATEDY RATIONALE TIME / VENUE / RESOURCES EVALUATION

Discussion and oral return demonstration

advanced stage. A large-scale loss of skin occurs, along with damage to underlying muscle, bone, and even supporting structures such as tendons and joints. f you've been immobilized, bedsores can be caused by: Sustained pressure. When your skin and the underlying tissues are trapped between bone and a surface such as a wheelchair or bed, blood flow is restricted. This deprives tissue of oxygen and other nutrients, and irreversible damage and tissue death can occur. This tends to happen in areas that aren't well padded with muscle or fat and that lie just over a bone, such as your spine, tailbone (coccyx), shoulder blades, hips, heels and elbows.

In some cases, the pressure that cuts off circulation comes from unlikely sources: the rivets and thick seams in jeans, crumbs in your bed, wrinkled clothing or sheets, a chair whose tilt is slightly off even perspiration, which can soften skin, making it more vulnerable to injury. Friction. Frequent shifts in position are the key to preventing pressure sores. Yet the friction that occurs when you simply turn from side to side can damage your skin, making it more susceptible to pressure sores. Shear. This occurs when your skin moves in one direction, and the

underlying bone moves in another. Sliding down in a bed or chair or raising the head of your bed more than 30 degrees is especially likely to cause shearing, which stretches and tears cell walls and tiny blood vessels. Especially affected are areas such as your tailbone where skin is already thin and fragile. In the early stages (1 and 2) of bedsores, the area may heal with relief of pressure and by applying care to the affected skin. A good diet will aid skin healing, especially by taking in enough vitamin C and zinc, which are available as supplements. For effective skin care: If the skin is not broken, gently wash the area with a mild soap and water. Clean open sores on the skin with salt water (saline, which can be made by boiling 1 quart of water with 1 teaspoon of salt for 5 minutes and kept cooled in a sterile container). Apply a thin layer of petroleum jelly (Vaseline) and then cover with a soft gauze dressing.

Be sure to keep urine and stool away from affected areas. To relieve pressure: Change positions often (every 15 minutes in a chair and every 2 hours in a bed). Use special soft materials or supports (pads, cushions, and mattresses) to reduce pressure against the skin. The first step in treating a sore at any stage is relieving the pressure that caused it. You can reduce pressure by:

Changing positions often. Carefully follow your schedule for turning and repositioning approximately every 15 minutes if you're in a wheelchair and at least once every two hours when you're in bed. If you're unable to change position on your own, a family member or other caregiver must be able to help. Using sheepskin or other padding over the wound can help prevent friction when you move. Using support surfaces. These are special cushions, pads, mattresses and beds that relieve pressure on an existing sore and help protect vulnerable areas from further breakdown.

The most effective support depends on many factors, including your level of mobility, your body build and the severity of your wound. No one support surface is appropriate for all people or all situations. In general, protective padding such as sheepskin isn't thick enough to reduce pressure, but it's helpful for separating parts of your body and preventing friction damage. You can use a variety of foam, air-filled or water-filled devices to cushion a wheelchair, but avoid using pillows and rubber rings, which actually cause compression. For your mattress, doctors often suggest lowair-loss beds or air-fluidized beds. Low-air-loss beds use inflatable pillows for support, whereas air-fluidized beds suspend you on an air-permeable mattress that contains millions of silicone-coated beads.

Other nonsurgical treatments of pressure sores include: Cleaning. It's essential to keep wounds clean to prevent infection. A stage I wound can be gently washed with water and mild soap, but open sores should be cleaned with a saltwater (saline) solution each time the dressing is changed. Avoid antiseptics such as hydrogen peroxide and iodine, which can damage sensitive tissue and delay healing.

Controlling incontinence as far as possible is crucial to helping sores heal. If you're experiencing bladder or bowel problems, you may be helped by lifestyle changes, behavioral programs, incontinence pads or medications. Removal of damaged tissue (debridement). To heal properly, wounds need to be free of damaged, dead or infected tissue. This can be accomplished in several ways the best approach depends on your overall condition, the type of wound and your treatment goals.

One approach is surgical debridement, a procedure that involves using a scalpel or other instrument to remove dead tissue. Surgical debridement is quick and effective, but it can be painful. For that reason, your doctor may use one or more nonsurgical approaches. These include removing devitalized tissue with a high-pressure irrigation device (mechanical debridement), allowing your body's own enzymes to break

down dead tissue (autolytic debridement), or applying topical debriding enzymes (enzymatic debridement). Dressings. A variety of dressings are used to help protect wounds and speed healing the type usually depends on the stage and severity of the wound. The basic approach, however, is to keep the wound moist and the skin surrounding it dry. Stage I sores may not need any covering, but stage II lesions are usually treated with hydrocolloids, or transparent semipermeable dressings that retain moisture and encourage skin cell growth. Other types of dressings may be more beneficial for weeping wounds or those with surface debris. Contaminated sores may also be treated with a topical antibiotic cream. Hydrotherapy. Whirlpool baths can aid healing by keeping skin clean and naturally removing dead or contaminated tissue. Oral antibiotics. If your pressure sores appear infected, your doctor may prescribe oral antibiotics. Healthy diet. Eating a nutritionally rich diet with adequate calories and protein and a full range of vitamins and minerals especially vitamin C and zinc may improve wound healing. Being well nourished also protects the integrity of your skin and guards against breakdown. If you're at risk of or recovering from a pressure sore, your doctor may prescribe vitamin C and zinc supplements.

Muscle spasm relief. This is essential for both preventing and treating pressure sores. To help alleviate spasticity, your doctor may recommend skeletal muscle relaxants that block nerve reflexes in your spine or in the muscle cells themselves.

Position changes Changing your position frequently and consistently is crucial to preventing bedsores. It takes just a few hours of immobility for a pressure sore to begin to form. For that reason, experts advise shifting position about every 15 minutes that you're in a wheelchair and at least once every two hours, even during the night, if you spend most of your time in bed. If you can't move on your own, a family member or caregiver must be available to help you. A physical therapist can advise you on the best ways to position yourself in bed, but here are some general guidelines: Avoid lying directly on your hipbones. On your side, lie at a 30degree angle. Support your legs correctly. When lying on your back, place a foam pad or pillow not a doughnut-shaped cushion under your legs from the middle of your calf to your ankle. Avoid placing a support directly behind your knee it can severely restrict blood flow. Keep your knees and ankles from touching. Use small pillows or pads.

Avoid raising the head of the bed more than 30 degrees. A higher incline makes it more likely that you'll slide down, putting you at risk of friction and shearing injuries. If the bed needs to be higher when you eat, place pillows or foam wedges at your hips and shoulders to help maintain alignment. Use a pressure-reducing mattress or bed. You have many options, including foam, air, gel or water mattresses. Because these can vary widely in price and effectiveness, talk to your doctor about the best choice for you. For some people, a low-air-loss mattress may provide enough support. But more expensive and technologically sophisticated beds may be needed for people who have recurring pressure sores or who are at very high risk.