Careplan

NURSING DIAGNOSES EXPECTED PATIENT ASSESSMENT ACTION TEACHING

OUTCOMES interventions: interventions: interventions:

Risk for Impaired Skin Integrity
r/t pt slumping on left shoulder
in WC, alteration in shoulder
sensory fields due to diabetes,
pts inability to transfer
independently, morbid obesity.
Pt will correctly reposition
body in WC while awake
every hour for 4 days ending
on 10/14/2017.
erythema or
-Monitor pts L. -Nurse will remind -Encourage pt to get out of
shoulder for pt every hour to WC and sit in recliner or
pressure ulcers and reposition posture in couches in living room.
watch for any WC for 4 days. Teach pt to use pillows or
foam wedges to prevent
moisture found in -Nurse will massage pressure injury.
that area. shoulders to reduce
muscle soreness and -Teach pt skin assessment
-Assess pts current apply lotion if skin and ways to monitor for
skin care practice appears dry. signs and symptoms of
noting frequency of infection like looking for
cleaning, if washed redness and swelling or
areas are properly reporting any pain to their
dried, and if lotion is provider.
applied.

Impaired physical mobility R/T
alteration in bone structure
integrity (R. ankle fracture,
cellulitis on R. leg); body mass
index >75th percentile for age
(morbidly obese) AEB use of
WC; unbalanced gait, leg
weakness; cast on fractured R.
ankle and cellulitis on R. lower
leg; morbid obesity.
Pt will build up leg strength
by using the Walker to stand
on L. leg for a minimum of 90
seconds two times a day at
0930, 2030 for 5 days ending
on 10/16/2017.
-Do complete pain -Nurse will -Encourage pt to verbalize
assessment every administer pain any pain felt with
shift. medications PRN. movement.
-Monitor pts ability -Nurse will assist -Teach pt to do deep
to tolerate activity with L. leg muscle breathing exercises to help
and use all 4 holding exercise and with lung expansion and
extremities noting execute passive and use an incentive spirometer
pulse, skin color, active ROM to promote better
and B/P before and exercises on pts left breathing when exercising.
after transfers and leg.
PT sessions.

References
Ackley, B. J., Ladwig, G. B., & Makic, M. B. (2017). Nursing diagnosis handbook: An evidence-based
guide to planning care (11th ed.). St. Louis, MO: Elsevier.
Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-surgical nursing:
Assessment and management of clinical problems(10th ed.). St. Louis, MO: Elsevier, Inc.