Care Plans
Related Factors
- Trauma
- Hot or cold temperature
- Impaired circulation/perfusion
- Fluid deficit /fluid excess
- Nutritional deficits/ excess
- Infection
- Chemical source
- Mechanical forces (friction, shear, pressure)
- Medical treatment/ radiation
- Impaired physical mobility
- Knowledge deficit
Subjective Data: patient’s feelings, perceptions, and concerns. (Symptoms)
- Expresses feelings of pain at the affected area
- States noticing oozing and drainage from the affected site
- Expresses frustration about lack of resources and knowledge to care for the wound
Objective Data: assessment, diagnostic tests, and lab values. (Signs)
- Tissue damage (integumentary, mucous membranes, corneal, subcutaneous tissue)
- Changes in the appearance of the affected area (redness, swelling, hot and tender to touch)
- Guarding of the affected area
- Grimacing
- Signs of systemic infection
- Elevated white blood cell count
- Elevated temperature
Expected Outcome
- The patient will maintain an intact tissue integrity
- The patient will verbalize a plan of care to maintain uncompromised tissue integrity
- The patient will be free of pain
- The patient will experience an improved wound healing process
- The patient will verbalize and demonstrate wound care correctly
Nursing Assessment
| Perform a complete body audit on admission and at designated times. Pay special attention to bony prominences that are at high risk for tissue injury. A complete head-to-toe audit provides the nurse with a baseline condition of the skin that can be used for comparison when skin damage is noted. |
| Obtain a thorough health history. Consider comorbidities such as diabetes, peripheral artery disease, past procedures, and nutritional status. Past medical history and the patient’s current clinical status often reveal conditions that explain the patient’s susceptibility to compromised tissue integrity. For example, diabetes mellitus can cause complications with wound healing because high blood sugars cause a delay in wound healing. Another example may be a patient recovering from recent surgery. With surgery incisions, this patient may have a greater risk for compromised skin integrity. Understanding the patient profile helps determine the right treatment plan. |
| Evaluate what causes the tissue damage. The etiology of compromised tissue can vary widely. Tissue can be compromised by acute or chronic health conditions, physical limitations, or equipment. This process is necessary so that appropriate interventions can be implemented. |
| Assess the affected area of tissue damage. Determine the size, depth, and other characteristics. Note the wound location. It may be helpful to use a visual aid such as a body diagram to mark all wounds and incisions. Use terms such as proximal, distal, anterior, medial, and posterior to clarify wound locations. |
| Determine the type of wound. There are several types of wounds. For example, if the wound is located over a bony prominence, it may be a pressure injury. A nurse that is specialized in wound care should be consulted to assist with appropriate wound staging. Use the staging criteria recommended by the National Pressure Ulcer Advisory Panel. |
Key features of pressure ulcers
Suspected Deep tissue injury:
– Skin is intact; appears purple or maroon
– Blood filled tissue due to underlying tissue damage
– Affected area may have felt firm, boggy, mushy, warmer, or cooler to touch
Stage 1
– Skin is intact but red and non-blanchable
– Area is usually over a bony prominence
Stage 2
– Partial-thickness skin loss
– Ulcer may be characterized as an abrasion or blister (open or fluid-filled)
– No bruising present
Stage 3
– Full-thickness skin damage
– Subcutaneous fat may be visible
– No bone, muscle, or tendon visible
Stage 4
– Full-thickness skin loss
– Palpable bone, muscle, and tendon tissue
– Slough and eschar present
Unstageable
– Full-thickness skin loss
– Area is entirely covered with slough and eschar, so the stage cannot be determined
| Note wound odor and drainage. Wound odor can come with exudate and may be a sign of infection. Note the amount of drainage present and the number of dressing changes necessary to keep the area dry. Color and amount of drainage provide information about appropriate wound healing processes. Serosanguinous drainage may be expected, while purulent drainage or pus may be signs of infection. As the wound heals, drainage should decrease. |
| Assess periwound tissue. It is essential to assess this area regularly because dressings are often secured at this area. In addition, noticing breakdown early in this area allows for pivot and implementation of other strategies to dress the wound. |
| Monitor for an elevated body temperature. Fever may be a sign of a systemic infection. |
| Monitor WBCs, prealbumin, albumin, and total protein levels. These values indicate signs of infection and malnutrition, which can cause tissue breakdown and complications with healing. |
| Assess the patient’s pain level. Tissue injury can be excruciating. Therefore, pain control is an integral part of the treatment plan. |
| Assess the patient’s mobility status and range of motion. Mobility limitations pose a risk factor for developing tissue damage. |
| Note whether the patient is incontinent or if there are areas of the body constantly exposed to moisture. Incontinence, wound drainage, and perspiration can be potential factors for skin breakdown. |
| Monitor placement of medical equipment. Positioning of tubes and drains can be a source of impaired tissue integrity if not monitored appropriately. Consistent pressure from medical devices against the skin without repositioning can lead to skin breakdown. |
Nursing Interventions for Impaired Skin Integrity
| Inspect the affected site at least once per day. Note changes such as color changes, redness, swelling, temperature, and pain. Pay attention if the patient notices changes in sensation and pain. Regular assessments allow the healthcare team to catch deteriorating wound conditions early and adjust treatment as necessary. |
| Use a tool such as the Braden Scale to identify patients at a high risk of developing pressure sores. The Braden Scale consists of factors that increase the risk of developing pressure ulcers. These criteria are sensory perception, moisture, activity, mobility, nutrition, and friction, and shear. The lower the number, the higher is the risk for the patient to develop a pressure injury. |
| For the immobile patient, turn and reposition the patient frequently. Regular position changes reduce pressure and shift pressure to different body areas, allowing adequate tissue perfusion and reducing the risk for skin breakdown. |
| Use friction and pressure-reducing items to help with the prevention of pressure sores. Items such as specialty mattresses, body aligners, pillows, moon boots, cushions, and sliding aids can help reduce pressure and friction, reducing the risk for tissue injury. |
| Bathe the patient daily with pH-balanced soap, use lotions and barrier creams, and change soiled underpads immediately. Prolonged contact of the skin with moisture and soil irritates the skin and predisposes it for skin breakdown. |
| Collaborate with dietary services to ensure nutritional needs are met. Nutrition plays a vital role in wound healing. Dietitians will make sure the patient receives an individualized diet plan that considers the correct diet, calories, and nutrients such as protein and vitamins. High-calorie and high-protein diets facilitate wound healing. |
| Clean the patient’s wounds according to hospital policy and orders. Wound cleaning usually requires an aseptic technique. Sterile technique reduces the risk for infection. |
| Administer antibiotics as ordered. To reduce the risk of infection or to treat an existing infection, either topical agents or intravenous medications are used. |
Patient Teaching
| Discourage the patient from rubbing and scratching the affected area. Friction can make already injured tissue worse. Bacteria could be introduced into open wound tissue and prolong the healing process. |
| Teach the patient and family about the correct wound care techniques. Handwashing Knowing the importance of clean dressing changes and the importance of each step reduces the risk of infection and complications. Return demonstrations by the family and written instructions might help solidify these skills. |
| Educate about the signs and symptoms of infection and when to notify healthcare personnel. Redness Being aware of these symptoms promotes early intervention. |
More Care Plans
References:
https://www.ncbi.nlm.nih.gov/books/NBK2650/table/ch12.t2/
https://www.woundsource.com/blog/understanding-braden-scale-focus-sensory-perception-part-1
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