NURSING CARE PLANS

1. Impaired Skin Integrity related to pressure ulcer secondary to prolonged immobility and
unrelieved pressure as evidenced by :
- pressure ulcers on sacral area ( stage 3 )
- left thigh( stage 3)
- left ankle
- prolonged immobility
- bedridden since 2014
- 4 months prior to admission redness over affected areas noted

Nursing Interventions:

Asses between folds of skin also assess under oxygen tubing especially on the ears and the
cheek, and under medical devices.
Note objective data of pressure ulcer ( stage, length, width, depth, wound bed, appearance,
drainage and condition of Periulcer tissue )
Increase the frequency of turning to sides every 2 hours. Position the client to stay off the
ulcer. If there is no turning surface without a pressure ulcer, use a pressure redistribution bed
and continue turning the client.
Elevate heels of bed by using pillows or heel elevation boots.
Maintain head of bed at lowest elevation, if client must have the head elevated to prevent
aspiration, reposition to 30 degree lateral position. Use seat cushions and assess sacral ulcers
daily.
Follow body substance isolation precautions; use clean gloves and clean dressings for wound
care.

Dependent /Collaborative:

Ensure adequate dietary intake, review dieticians recommendations. Prevent the ulcer from
being exposed to urine and feces. Use indwelling catheters, bowel containing system, and
topical creams and dressings.
Supplement the diet with vitamins and minerals. Vitamins C and zinc are commonly
prescribed.
Provide oral supplementations, tube feedings or hyperalimentation to achieve positive
nitrogen balance.
Removed devitalized tissue from the wound bed except from the avascular tissue or on the
heels. Began by cleansing the ulcer bed with normal saline, then use appropriate technique for
debridement. Once the ulcer is free of devitalized tissue, apply dressing the wound bed moist
and the surrounding skin dry. Do not use the occlusive dressing on ulcer.

Rationale:

Pressure ulcers under medical devices are commonly overlooked.

Reassessment of ulcer is completed each time dressing are changed or sooner if ulcer shows
manifestations or deterioration. Analyses of the trends in healing are more important step in
assessment.

To disperse pressure overtime or decreasing the tissue load

Heel covers do not relieve the pressure, but they can reduce friction.
To prevent further occurrence of pressure ulcer
To reduce risk of infection and promote faster healing.
To prevent malnutrition and delayed healing.
To prevent spread of infection/contamination.
To promote wound healing on clients who do not have adequate calories.
Pressure ulcers cannot heal clients with severe malnutrition.
To promote faster healing and reduce infection.

2. Self-care deficit related to muscle weakness secondary to paralysis as evidenced by:

- Stroke in 2014 made the client bedridden
- Client has weak lower extremities
- Clients left arm is weaker than the right
- Client depends on another person in maintaining activities of daily living
Nursing interventions:

Assess abilities and level of deficit (04 scale) for performing ADLs.
Avoid doing things for patient that patient can do for self, but provide assistance

as necessary.
Be aware of impulsive actions suggestive of impaired judgment.
Maintain a supportive, firm attitude. Allow patient sufficient time to accomplish

tasks. Dont rush the patient.

Provide positive feedback for efforts and accomplishments.
Create plan for visual deficits that are present: Place food and utensils on the tray
related to patients unaffected side; Situate the bed so that patients unaffected
side is facing the room with the affected side to the wall; Position furniture against

wall/out of travel path.

Provide self-help devices: extensions with hooks for picking things up from the
floor, toilet risers, long-handled brushes, drinking straw, leg bag for catheter,

shower chair. Encourage good grooming and makeup habits.

Encourage SO to allow patient to do as much as possible for self
Assess patients ability to communicate the need to void and/or ability to use
urinal, bedpan. Take patient to the bathroom at periodic intervals for voiding if

appropriate.
Identify previous bowel habits and re-establish normal regimen. Increase bulk in

diet, encourage fluid intake, increased activity.

Teach the patient to comb hair, dress, and wash.
Refer patient to physical and occupational therapist.

Rationale:

Aids in planning for meeting individual needs.

To maintain self-esteem and promote recovery, it is important for the patient to do
as much as possible for self. These patients may become fearful and

independent, although assistance is helpful in preventing frustration.

May indicate need for additional interventions and supervision to promote patient

safety.
Patients need empathy and to know caregivers will be consistent in their

assistance.
Enhances sense of self-worth, promotes independence, and encourages patient

to continue endeavors.
Patient will be able to see to eat the food. Will be able to see when getting in/out
of bed and observe anyone who comes into the room. Provides for safety when
patient is able to move around the room, reducing risk of tripping/falling over
furniture.