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Nursing Care Plan ____________________________________________________________________________________________________________________________Nursing DiagnosisGoalsInterventionsRationaleEvaluationImpaired skin integrity,impaired wound healing,nutritional imbalance,diabetes.Monitor the skincondition andassociated riskfactors tomaintain skinintegrity.Risk assessment anddocumentation of skin integrity byuse of assessment tools.Proper wound dressing, cleansing,debriding, management of bacterialand moisture balance. Treatment ofwound infection with Prontosan.Complimentary therapies likenatural herbs, aloe vera, honey,among others (Dorai, 2012). Assessment tools helpsto determine the woundsize, depth, woundedges, presence ofexudates, periwoundskin, wound pain andodour, determination oftissue type like granular,necrotic or slough.Proper healing of woundand absence of exudates,foul odour, pain, necrotictissues. Promotion ofcirculation intissues to reducepressure.Redistribution of bed and wheelchairsurface, providing heel lift, use ofpositioning devices like foamswedges, pillows, monitoring andassessment of pain bydetermination of pain triggers,management of pain byadministration of opioids likemorphine, hydrocodone, amongothers. Diabetes management byadministration of insulin, nutritioncheck. These help to promotecirculation in the tissuesthereby helping toeliminate pressure.It also helps to managepain associated withimpaired wound healingand also helps in themanagement of diabetes.Absence of pain, properlymanaged sugar levels,increased circulationresulting in improvementsin wound healing and skinintegrity.PreventUse of barrier ointment, pericareIncontinence andLow amount of moisture
breakdown ofskin which isassociated withpresence ofexcess moisture.after episodes of incontinence,washing of clothes to removeexcess perspiration.perspiration can lead toexcess moisture, whichimpairs wound healing.and maintenance ofeffective moisture balance.Preventingdamage to skinby removingfrictional orshearing forces.Use of skin sealants and lubricants,use of lifting devices, bathing withmild soaps to prevent shearing ofthe skin.Referrals to dermatologists forimprovements of skin integrity.Fragile or impaired skincan result in shearing ordamage and the use ofthese interventions helpsto prevent damage tofragile skin. Proper skin integrity andabsence of damage toskin. Promotion ofproper nutritionin aid in woundhealing.Provingnutritionalsupplementations, vitamins andminerals, referrals to dietitians,monitoring of diets and preparingindividualized diets according topatient preference. Nutritional imbalanceleads to impaired skinintegrity and delay inwoundhealing.Moreover, propernutritionis also essential tomanage diabetes, whichis associated withimpaired skin integrityand delay in woundhealing.Nutritionalstatusassessment by using theMUST score and nutritioncare planning following theevaluation of the MUSTscore.Education topatients for selfmanagement ofwounds.Patient education on causes, risks and benefits of interventions. Psychosocial support for those suffering from wound related psychological problems (In.gov, 2018).Pain associated withwounds can lead topsychological problemslike anger, anxiety,depression, stress. Evaluation of patientlearning and reducedpsychological stress inpatients with delayedwound healing.
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