NURSING MISCNursing Care Plan Forms Part 2 J.H..docx

Nursing Diagnosis #1: Impaired Tissue integrity related to impaired physical mobility as evidenced by stage 4 Pressure Ulcer on left dorsal foot. Goal: Patient will regain tissue integrity on left dorsal foot as evidenced by reduction of pressure injury stage by March 28,2019. MET Outcome Criteria: (The goal has been met if the client…) 1. By 03/28/2019, patient will be able to show reduction of pressure injury stage after performing wound care daily. MET 2. By 03/28/2019, patient will not develop any further damage on the pressure ulcer site. MET 3. By 03/28/2019, patient will verbalize the importance of using pressure-reducing devices especially for bedbound patients MET Priority Nursing Interventions Scientific Rationale For Every Intervention Evaluation of each Nursing Intervention 1. Student nurse will assess site of tissue impairment and determine the cause. The cause of the wound must be determined before appropriate interventions can be implemented. This will provide the basis for additional testing and evaluation to start assessment process. Patient’s left dorsal foot has presence of stage 4-pressure ulcer. Patient has limited mobility on bilateral lower extremity. 2. Inspect and monitor site of tissue impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection. Systematic inspection can identify impending problems early Patient shows no sign of infection. 3. Select and perform a wound care daily that maintains a moist, wound-healing environment and also allows absorption of exudate and filling of dead space. Each type of wound is best treated based on its etiology. Skin wounds may be covered with wet or dry dressings, topical creams or lubricants, hydrocolloid dressings (e.g., DuoDerm) or vapor-permeable membrane dressings such as Tegaderm. The dressing Patient responds positively on the treatment plan and show signs of healing on the wound site but not completely healed.