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Risk for Impaired Skin Integrity Care Plan
Nursing Concepts Practicum (NSG 3314)
Troy University
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TROY UNIVERSITY BSN PROGRAM
Patient-Centered Care Plan
Student’s Name: Allyson Register Age: 73 Sex: M Room No. N/A
Patient’s Initials: L. Long-term Goal: Patient will retain skin integrity during and
after discharge from hospital.
Medical Dx: cerebrovascular accident
Surgical Dx: ____________________
Admitting Dx: cerebrovascular accident
ASSESSMENT ANALYSIS PLAN IMPLEMENTATION EVALUATION
Data Collection Subjective & Objective
Nursing Diagnosis Patient-centered Goals Measurable Outcome
Nursing Orders/Action Include Rationale & References
Evaluate Each Outcome Criterion & Make Recommendations
Subjective Client is 73 years old
0800: patient reports no pain
01200: patient reports pain in chest when coughing, patient rates pain as a 2/
Objective Weakness on the right side of the body
Unable to grasp with the right hand
Only able to elevate right arm and leg an inch off the bed
Risk for impaired skin integrity related to limited physical mobility as evidenced by weakness in client’s right side, inability to ambulate or turn himself in bed, and area of blanchable erythema on client’s right hip.
Patient’s skin will be free from complications of immobility by 10/01/2021 at 1500 as evidenced by:
- Patient will be free of blanchable erythema on the right rip.
On 9/17/2021 from 0700-1500 Troy University BSN Student will perform the following:
1a. Assess skin of patient’s right hip for blanching by palpating q4h starting at 0700. Rationale: “Although not a pressure injury, blanching (becoming pale and white) of the skin area under pressure may be an early warning sign of potential injury development.” (Taylor, et. al., 2021, p. 1064).
1b. Inspect skin of patient’s right hip for signs of erythema q4h starting at 0700. Rationale: “A stage 1 pressure
Overall Goal Met
- Goal Met: Patient is free of blanchable erythema on the right hip as of 1500 on 10/01/2021. 0700: Area of blanchable erythema still noted over the right hip. 1100: Patient’s hip is free of erythema.
Recommendation: Continue assessing patient’s skin for new areas of blanchable or
Unable to ambulate or turn himself
Area of blanchable erythema to client’s right hip
VS
0800: blood pressure 176/99 mm Hg , pulse 88 beats per minute , respirations 24 breathes per minute , temperature 97 degrees Fahrenheit
1200: blood pressure 157/88 mm Hg , pulse 90 beats per minute , respirations 22 breathes per minute , temperature 99 degrees Fahrenheit
- Patient will be free of pressure ulcers.
injury is a defined, localized area of intact skin with nonblanchable erythema (redness).” (Taylor, et. al., 2021, p. 1065).
2a. Use the Braden Scale to assess the patient’s risk for pressure ulcers at 0700 and reassess level of risk at the beginning of each shift. Rationale: “The degree of risk is based on the patient’s total score. Using the Braden scale, a score of 19 to 23 indicates no risk; 15 to 18, mild risk; 13 to 14, moderate risk; 10 to 12, high risk; and 9 or lower, very high risk.” (Taylor, et. al., 2021, p. 1064).
2b. Reposition patient in bed q2h beginning at 0700 to prevent skin breakdown. Alternating from supine to left side lying position with each position change. Rationale: “Assessing a patient’s mobility includes evaluating the patient’s ability to move, turn, and reposition the body. A patient who is confined to bed or a chair, or has limited range of motion is at increased risk for a pressure injury.” (Taylor, et. al., 2021, p. 1064).
non- blanchable erythema using inspection and palpation daily until discharge.
- Goal Met: Patient is free of any pressure ulcers as of 1500 on 10/01/2021. 0700: Patients Braden score noted as 14. Position change from supine to left side lying. 0900: Position change from left side lying to supine position. 1100: Position change from left side lying to supine position. 1300: Position change from supine to left side lying position. 1500: position change from left side lying to supine position.
Recommendation: Continuing assessing the patient using the Braden scale at the beginning of each shift and perform position changes every 2 hours.
reason, cells receive inadequate nourishment and cannot remove wastes efficiently.” (Taylor, et. al., 2021, p. 1045).
evaluation on clients understanding of the causes of skin breakdown.
ASSESSMENT ANALYSIS PLAN IMPLEMENTATION EVALUATION
Data Collection Subjective & Objective
Nursing Diagnosis Patient-centered Goals Measurable Outcome
Nursing Orders/Action Include Rationale & References
Evaluate Each Outcome Criterion & Make Recommendations
Risk for Impaired Skin Integrity Care Plan
Course: Nursing Concepts Practicum (NSG 3314)
University: Troy University
