Priority:

Nursing Diagnosis

Short Term Goals

Interventions

Rationale

Evaluation

2

Impaired Skin Integrity

 1. pts pressure ulcer will show signs of healing and not breakdown during morning shift.

A.  Skin surveillance q8h and also c periods of incontinence and time of shower.

B. Positioning q3h

C. Cleanse wound qd, when incontinence occurs and also after showers.

D. Ensure proper nutrition q8h c each meal.

 A.  To determine a baseline for skin integrity at beginning of the shift and also to make sure further break down is not occurring.

B.  To relieve pressure on skin, especially bony prominences.

C. Cleaning pressure ulcer reduces chance of infection and when dried poperly reduces moisture which helps to reduce potential breakdown.

D. Adequate nutrition is essential to improve skin integrity and protein especially helps wound healing.

Short Term Goals:

Impaired skin integrity puts G.P. at risk for infection.  The short term goals listed promote healing prevention from future breakdown.

Related to:  incontinence, hemi paralysis, neuromuscular and musculoskeletal impairment

Effectiveness of interventions: Why or why not?

A.       Effective because this intervention helps to recognize if improvement or deterioration is occurring.

B.       Positioning will be effective when used over an extended period.

C.      Cleansing and drying ulcer was effective because no signs of infection were observed.

D.      Effective because G.P. ate 100% of meal that consisted of two sources of protein.

Secondary to:    stroke

Defining Characteristics:  Stage I pressure ulcer, 2x2” on upper right buttock.  Moist skin from urinary incontinence, and increased pressure on tissues due to impaired mobility.

Appropriate Nursing Diagnosis? Reason

This diagnosis is appropriate because he has a pressure ulcer that needs to be evaluated and treated to prevention infection.