PLANNING/IMPLEMENTATION/EVALUATION (See Grading Rubric for NCP Criteria)
Nursing Diagnosis: Impaired Skin integrity r/t inability to reposition self aeb stage III pressure ulcer in coccyx area.
Long Term Goal: Patient will maintain optimal skin integrity
Outcome Criteria
Interventions
Patient will rate pain using 1-10 pain
scale as assessed q 4hrs
Monitor:
Monitor pain level q 4hrs
Patient will not remain in same
position for more than two hours
Independent:
Reposition patient q 2hrs
Rationale
The patient is able to verbalize pain and discomfort
that she experiences when in an uncomfortable
position. This discomfort or pain is caused by
decreased circulation and damage in the soft tissues,
and could indicate ischemia. While the patient has
progressive dementia, she is still able to verbalize
pain and rate it using a 10-1 scale. By regularly
monitoring the patient’s pain level, it could give early
indication of possible ischemia and allow for early
detection of skin break down. This will allow for
early intervention of skin breakdown and will help to
maintain optimal skin integrity. It should be noted
that this intervention may not be as effective when
the patient is actively using pain medication. NURS
101 lecture, class notes, clinical; NURS 215 clinical;
Nursing Care Plans 187
When the patient lies in a position for any length of
time, the pressure between bony prominences and the
bed causes the blood flow to be restricted in the
capillary beds of the affected area. This restricted
blood flow causes tissue ischemia and, if prolonged,
necrosis. The development of a pressure ulcer can be
prevented if the pressured area is relived within 2-3
hours. This relief of pressure allows the ischemic area
to receive oxygenation before necrosis occurs and
prevents compromised skin integrity. NURS 101,
lecture, class notes; Perry & Potter 1304
Evaluation
Met
Ongoing
Met
Ongoing
Outcome Criteria
Interventions
Rationale
Evaluation
Patient’s family will state two
strategies for helping patient to
maintain optimal nutrition following
consultation with dietitian
Collaboration:
Consult with dietitian within 24hrs of
admission
This patient has severe oral dysphagia which greatly
hinders her ability to maintain an adequate intake
which will provide the nutrients necessary for healing
and maintenance of the integumentary system. A
dietitian has the unique training necessary to
recommend a diet and feeding strategies that will
safely promote optimum intake of needed nutrients.
Maintaining a diet that encourages nutrition,
especially protein and iron, will promote wound
healing and help to prevent future impairment of the
patient’s skin. Lewis 87; NURS 102 lecture
Unmet
Intervention not
implemented during
clinical
Patient’s family will verbalize three
causes of skin breakdown following
teaching
Teaching:
Teach family causes of skin
breakdown within 48hrs of admission
The patient has dementia which limits her ability to
benefit from teaching; however her family, especially
her daughter, appears to be quite involved in her care.
By teaching her family the pathology of skin
breakdown, they will have a better understanding of
the purpose of the interventions and will be more
likely to comply with medical advice. The family
should be taught about the negative effect of
prolonged pressure on boney prominences, the effects
of nutrition on maintaining skin integrity, and the
negative effects of shearing forces on the skin.
Having the family verbalize these pathologies will
allow evaluation of the short term effects of teaching;
long term effects may be evaluated by watching for a
change in the family’s practices. This teaching should
result in a change in their practices and will help to
ensure their collaboration with medical professionals
to prevent skin breakdown. Nursing Care Plans 189;
NURS 101 lecture, class notes; NURS 102 clinical
Partially met
Patient’s daughter
verbalized one cause
of skin breakdown
Outcome Criteria
Interventions
Rationale
Evaluation
Patient will consume 300ml of Ensure
q 3 hrs while awake
Independent:
Encourage consumption of Ensure q
3hrs while awake
One of the primary nutrients needed to maintain
optimal skin integrity is protein. All cells are made of
protein at the molecular level; in order to continue to
produce skin cells as the old are shed, and to produce
tissues needed to the patient’s heal pressure ulcer, an
adequate intake of protein is needed. The minimum
recommended daily intake of protein is 40g and a
300ml Ensure contains 9g of protein. If taken at
regular intervals with three missed due to the patient
sleeping, her intake of protein will be 45g of protein,
above the daily minimum. Ensure is also ideal for this
patient as its thickness will make is easier for the
patient to swallow while on aspiration precautions.
When other sources of protein are included, her
protein intake will be at a therapeutic level to
promote optimal skin integrity. NURS 217 lecture;
NURS 212 lecture, class notes; NURS 101 lecture
Partially met
Patient consumed
Ensure, but did not
meet outcome criteria
Patient will remain in KCI bed at all
times
Dependent:
Use KCI bed at all times PP 1304
As the patient it particularly vulnerable to skin
impairment due to pressure on boney prominences,
she should be placed on the mattress that is most
therapeutic. The best option would be the KCI bed,
which pumps a layer of air between the patient and
the mattress, and adjusts to ensure that one area is not
pressured for longer than 2 hours. It should be noted
that the frequency of this intervention should be
modified if the patient is able to safely leave her bed.
By using the KCI mattress, the possibility of further
skin damage is lessened compared to a standard
mattress; however a regular turning schedule should
not be neglected or replaced because of the use of a
KCI mattress. Perry & Potter 1304; NURS 101
lecture; NURS 102 clinical; NURS 217 clinical
Met
Ongoing
Outcome Criteria
Interventions
Patient’s oral intake will be
2000-3000ml per day
Independent:
Provide and encourage fluids q 2 hrs
Patient will maintain urinary output of
at least 30ml/hr and within 200ml of
the total input for the shift as assessed
q shift
Monitor:
Monitor urinary output q shift
Rationale
Evaluation
As this patient is on a nectar thick diet, her sole
source of liquids is through the dietary trays unless
provided by nursing staff. To maintain adequate fluid
intake and because she is incapable of drinking by
herself, these fluids should be provided by nursing
staff at least every two hours. The patient should
maintain a fluid intake of 2000-3000ml/day, which is
reasonable given her baseline is over 800ml/shift. If
the patient is adequately hydrated her integumentary
and subcutaneous cells will be able to function better,
taking longer for them be affected by prolonged
ischemia. Adequate hydration will also promote a
healthy fluid volume in the intravascular space, which
will facilitate the maintenance of blood flow to
unaffected areas and will also allow for more blood to
flow to the affected area, promoting healing. Potter &
Perry 1307; NURS 101 lecture; NURS 102 lecture
Met
Ongoing
The patient’s urinary output should be monitored to
allow evaluation of possible fluid retention. As the
patient already has +1 pitting edema in her ankles due
to decrease oncotic pressure and poor circulation, she
is a risk for increased fluid retention. Increased fluid
retention will cause increased edema, causing the skin
to become ore taunt and susceptible to tears. As the
patient is on comfort care and bedridden, monitoring
her output is a comfortable alternative to weighing
her daily and is very practical as she has an
indwelling urinary catheter. Monitoring her output
will indicate if further interventions are needed to
prevent edema and the associated risks. NURS 101
lecture; NURS 102 lecture, clinical, Potter & Perry
1304
Met
Ongoing
Outcome Criteria
Interventions
Patient will be assessed and evaluated
by wound nurse within 48hrs of
admission
Collaboration:
Consult with wound nurse within
48hrs of admission
Patient will receive barrier cream to
unaffected area at risk for
contamination q 4hrs
Independent:
Apply barrier cream to unaffected skin
q 4hrs
Rationale
The wound nurse is specially trained and experienced
in assessing and planning treatment for wounds like
the pressure ulcer this patient has. His of her
assessment and plan for patient treatment will help to
guide other nursing interventions that may not be
considered otherwise. Although the patient’s care is
palliative, the wound nurse’s expertise will still be
useful in recommending ways to help maintain
optimal skin integrity and promote healing as
possible. NURS 215 clinical, Potter & Perry
1307-1310
This patient has very poor control of her external anal
sphincter due to the progression of her dementia. The
resulting fecal incontinence causes the intact skin in
the sacral area around the wound to become moist
and contaminates it with bacteria and enzymes,
creating an environment that promotes skin
breakdown. Although the patient will be monitored
frequently for incontinence, it will be impossible to
catch immediately each time as she is not at a level of
communication with nursing staff that allows for her
expressing she has been incontinent. By applying
barrier cream frequently, her fecal matter will not
have direct contact with her skin, nullifying the
possible complication caused by fecal contamination
and ensuring optimal skin integrity. Perry & Potter
855, 1304-1310
Evaluation
Unmet
Intervention not
implemented during
clinical
Met
Ongoing
Outcome Criteria
Interventions
Rationale
Evaluation
Patient will maintain a clear liquid,
nectar thick diet by teaspoon only at
all times
Dependent:
Clear liquid, nectar thick diet by
teaspoon only at all times
This patient has severe oral dysphagia which affects
her ability to maintain an adequate intake. This
disrupts the provision of the nutrients necessary for
healing and maintenance of the integumentary
system. The doctor has prescribed a diet and feeding
strategies that will safely promote intake of needed
nutrients and will encourage the patient to continue
taking them. By reducing the possibility of aspiration,
the patient will be more likely to cooperate with a diet
that encourages optimal nutrition. This will promote
wound healing and help to prevent future impairment
of the patient’s skin. NURS 102 lecture; Potter and
Perry 1304-1306
Met
Ongoing
Patient’s bony prominences will be
offloaded at all times
Independent:
Offload bony prominences at all times
When the patient lies in a certain position for any
length of time, the pressure between bony
prominences and the bed causes blood flow to be
restricted in the capillary beds of the pressured area.
This restricted blood flow causes tissue ischemia and,
if prolonged, may cause necrosis. The possible risk
factor can be avoided if the bony prominences are
elevated using pillows. This relief of pressure allows
the ischemic area to receive oxygenation and prevents
necrosis and compromised skin integrity. The heels
are the easiest to offload with a pillow under the legs,
the pelvic bones may have to be offloaded one side at
a time, and any other possible pressure points should
be offloaded as much as possible. NURS 101, lecture,
class notes, clinical; NURS 102 lecture, clinical;
Perry & Potter 1304
Met
Ongoing
Outcome Criteria
Interventions
Rationale
Evaluation
Patient will have clean wet to dry
dressing on pressure ulcer at all times
Dependent:
Apply wet to dry dressing q shift or
PRN
The patient has a stage III pressure ulcer in her sacral
area that is healing poorly, and requires a dressing. A
wet to dry dressing is ideal for this wound as it allows
a moist environment for the formation of granulation
tissue and can wick sloughing tissues away from the
wound bed. A dry dressing would damage any
granulation tissues that formed when removed and
would not help to remove slough from the wound
bed. By having a dry protective covering over the wet
gauze in the wound, the wound bed will be protected
from contamination, which is especially important as
the wound is in the sacral area and the patient is
frequently incontinent. By providing a wet to dry
dressing whenever the former dressing is soiled, but
at least every 8 hours, optimal healing and wound
protection will be occur. Potter & Perry 1311-1314;
NURS 101 lecture
Met
Ongoing
Patient will be assessed using 6-23
Braden scale q shift
Assess:
Assess breakdown risk using Braden
scale q shift 14 23
The Braden scale is an objective, evidenced based
scale used to assess the patient’s risk for developing
pressure ulcers. This scale bases their risk on sensory
perception, moisture, activity, mobility, nutrition, and
sheer. The patient’s current Braden score is 14, which
indicates a moderate risk for further pressure ulcer
development. By monitoring the Braden scale each
shift, it will allow for early detection of an increased
risk of pressure ulcer development, and will indicate
the effectiveness of current interventions and if
further interventions are needed. Potter & Perry 1289;
NURS 101 lecture, class notes, clinical; NURS 102
clinical
Unmet
Intervention not
implemented during
clinical
Outcome Criteria
Interventions
Rationale
Evaluation
Patient will remain free of fecal
soiling at all times
Monitor:
Monitor patient for incontinence q
2hrs and PRN
The patient has impaired control of her external anal
sphincter due to her disease process. The resulting
fecal incontinence causes the intact skin in the sacral
area around the wound to become moist and
contaminates it with bacteria and enzymes,. The fecal
matter may also penetrate the dressing and
contaminate the wound bed if not promptly
addressed. Although it may not be possible to
determine immediately that the patient has been
incontinent when it occurs, frequent checks will help
to keep the patient as clean as possible. This task can
also be delegated, helping to maintain efficient
nursing care delivery. Frequent monitoring of the
patient’s hygienic needs will decrease the probability
of complications caused by fecal contamination and
help to ensure optimal skin integrity. Perry & Potter
855, 1304-1310, 868; NURS 102 lecture, clinical
Met
Ongoing
Patient’s pressure ulcer’s diameter
will shrink by 1cm within 2 weeks
Assess:
Assess pressure ulcer q dressing
change
The patient has a stage III pressure ulcer that is 8cm x
6cm x 2cm in sacral area. By measuring and
assessing the pressure ulcer it will be possible to tell
if it is healing and reducing in size, and if the wound
bed contains granulation tissue or necrotic tissue.
This continuous assessment allows evaluation of
interventions already implemented and may indicate
if new interventions should be considered to help
maintain optimal skin integrity. NURS 101 lecture,
class notes; NURS 102 lab
Unmet
Timeframe exceeds
ability to evaluate
Outcome Criteria
Interventions
Patient will not receive sheer injuries
at all times
Independent:
Position patient to minimize sheer
injuries at all times
Patient and patient’s family will meet
and communicate with hospice
agency 24hrs prior to patient’s
discharge
Collaboration:
Refer hospice 24hrs before discharge
Rationale
Because the patient has frail skin, she is at risk for
skin tears that may result as she changes positions.
Skin tears are caused when friction of the skin against
the bed causes a separation of the fascia from the
dermal layer and the subcutaneous tissue, allowing
the skin to tear. By reducing friction by gatching the
patient’s lower extremities, elevating them on
pillows, and positioning pillows to limit sheering
forces on the patient, it will be possible to reduce the
probability of skin tears and maintain optimal skin
integrity. Potter & Perry 1304-1310; NURS 101
lecture
When the patient is discharged, she will be going
home and living with her daughter who is in her 60s.
For the patient to have complete and correct care it
will be necessary for the patient’s daughter to have
professional assistance. As hospice will be necessary
to meet the patient’s palliative needs, and as correct
maintenance of the patient’s skin integrity promotes
her comfort, it will be within their scope of practice
and objectives to maintain optimal skin health. Lewis
87; NURS 102 lecture
Evaluation
Met
Ongoing
Unmet
Intervention had not
yet been started
Outcome Criteria
Interventions
Rationale
Evaluation
Patient’s skin turgor will remain
non-tenting as assessed q 8hrs
Assess:
Assess patient’s skin turgor q 8hrs and
PRN
Skin cells have a ridged, formed shape they form
together as an organ; this shape is partially
maintained from the pressure of the cell contents
against the cell membrane. When the patient’s
hydration is inadequate it causes the skin to regain its
normal shape much slower when displaced by tenting
it. If the skin immediately returns to its original
placement it indicates adequate hydration. When the
patient is adequately hydrated her integumentary and
subcutaneous cells will be able to function better,
taking longer for them be affected by prolonged
ischemia. Adequate hydration will also promote a
healthy fluid volume in the intravascular space, which
will facilitate the maintenance of blood flow to
unaffected areas and will also allow for more blood to
flow to the affected area, promoting healing. Potter &
Perry 1307; NURS 101 lecture; NURS 102 lecture
Met
Ongoing
Patient will remain free of urinary
incontinence at all times
Dependent:
Foley catheter to gravity at all times
The patient’s dementia and UTI has altered her
control over her urethral sphincter causing her to have
urinary incontinence. By having a Foley catheter in
place, not only does the patient have a more accurate
way of measuring urinary output, but she also has a
way to avoid having urine in contact with her skin.
Urine is high in ammonia which can catalyze skin
breakdown; by avoiding urine on the skin, current
skin integrity is maintained and further breakdown
can be avoided. NURS 101 lecture; NURS 102
lecture, class notes, clinical
Met
Ongoing