Sample Care Plan Template Page 48
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51Nursing Diagnosis and Priority # 5:
Risk for impaired skin integrity R/T altered nutritional status, altered circulation, altered metabolic state, mechanical factors, moisture,
AEB patient on bedrest, diagnosed with malnutrition, position immobility, use of 2-points restraints, and Braden scale score of 9.
General Goal:
The patient will maintain his skin integrity and not breakdown during my nursing shift.
Outcome Objective(s): (use SMART format)
1. The nurse will turn the patient q2hrs to help preserve skin integrity and prevent development of pressure ulcers during the nursing
shift.
2. The nurse will evaluate the necessity of restraints q2hrs to help prevent altered circulation and preserve skin integrity during the
nursing shift.
3. The nurse will perform daily care qshift and PRN to prevent the build up of moisture in skin folds and perianal area during the
nursing shift.
Patient Responses
Interventions with time frames/frequency
Rationale (for each intervention)
(subjective/objective data)
1) Monitor necessity and site of patient’s 2-point
1) Mechanical forces such as friction,
1) The patient was restraints were
soft restraints q2hrs because there friction of the
pressure, and shearing can cause/accelerate
assessed q2hrs and were determined
skin can lead to skin breakdown.
skin breakdown (Ackley & Ladwig, 2011).
necessary due to sedation agitation
and pulling at lines. Sites of
restraints were inspected q2hrs for
signs of decreased circulation or
skin breakdown. No signs of skin
breakdown or altered circulation
were noted during the shift.
2) The patient’s skin on his bony
2) The patient is on bedrest and sedated so he has
2) Pressure ulcers are more likely to
limited mobility. The condition of his skin was
develop over bony prominences in patients
prominences was assessed
assessed throughout the shift and special
with limited mobility (Magnan &
throughout the shift and there were
attention was paid to the skin covering his bony
Maklebust, 2009).
no signs of skin breakdown noted
prominences (Ackley & Ladwig, 2011).
during the shift.
F:\group\MEPN\MEPN Level III\NURS610B\2013NURS 610B\610BCarePlan
12/17/2012
page 28
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