Nursing Care Plan: Wound Healing, Skin Integrity, and Diabetes

This report presents a comprehensive nursing care plan focusing on wound healing, skin integrity, and diabetes management. It outlines the nursing diagnosis, goals, and interventions, including risk assessment, wound care techniques (such as the use of Prontosan and complementary therapies), and the importance of maintaining moisture balance. The plan emphasizes the use of assessment tools to determine the wound's condition and the implementation of interventions to promote healing, such as managing pressure, providing nutritional support, and preventing skin damage. The report also includes patient education on wound management, and the provision of psychosocial support for patients experiencing psychological problems related to wounds. The reference list includes sources such as the Indian journal of plastic surgery, and In.gov.

Nursing Care Plan
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Nursing Diagnosis Goals Interventions Rationale Evaluation
Impaired skin integrity,
impaired wound healing,
nutritional imbalance,
diabetes.
Monitor the skin
condition and
associated risk
factors to
maintain skin
integrity.
Risk assessment and
documentation of skin integrity by
use of assessment tools.
Proper wound dressing, cleansing,
debriding, management of bacterial
and moisture balance. Treatment of
wound infection with Prontosan.
Complimentary therapies like
natural herbs, aloe vera, honey,
among others (Dorai, 2012).
Assessment tools helps
to determine the wound
size, depth, wound
edges, presence of
exudates, periwound
skin, wound pain and
odour, determination of
tissue type like granular,
necrotic or slough.
Proper healing of wound
and absence of exudates,
foul odour, pain, necrotic
tissues.
Promotion of
circulation in
tissues to reduce
pressure.
Redistribution of bed and wheelchair
surface, providing heel lift, use of
positioning devices like foams
wedges, pillows, monitoring and
assessment of pain by
determination of pain triggers,
management of pain by
administration of opioids like
morphine, hydrocodone, among
others. Diabetes management by
administration of insulin, nutrition
check.
These help to promote
circulation in the tissues
thereby helping to
eliminate pressure.
It also helps to manage
pain associated with
impaired wound healing
and also helps in the
management of diabetes.
Absence of pain, properly
managed sugar levels,
increased circulation
resulting in improvements
in wound healing and skin
integrity.
Prevent Use of barrier ointment, pericare Incontinence and Low amount of moisture

breakdown of
skin which is
associated with
presence of
excess moisture.
after episodes of incontinence,
washing of clothes to remove
excess perspiration.
perspiration can lead to
excess moisture, which
impairs wound healing.
and maintenance of
effective moisture balance.
Preventing
damage to skin
by removing
frictional or
shearing forces.
Use of skin sealants and lubricants,
use of lifting devices, bathing with
mild soaps to prevent shearing of
the skin.
Referrals to dermatologists for
improvements of skin integrity.
Fragile or impaired skin
can result in shearing or
damage and the use of
these interventions helps
to prevent damage to
fragile skin.
Proper skin integrity and
absence of damage to
skin.
Promotion of
proper nutrition
in aid in wound
healing.
Proving nutritional
supplementations, vitamins and
minerals, referrals to dietitians,
monitoring of diets and preparing
individualized diets according to
patient preference.
Nutritional imbalance
leads to impaired skin
integrity and delay in
wound healing.
Moreover, propernutrition
is also essential to
manage diabetes, which
is associated with
impaired skin integrity
and delay in wound
healing.
Nutritional status
assessment by using the
MUST score and nutrition
care planning following the
evaluation of the MUST
score.
Education to
patients for self
management of
wounds.
Patient education on causes, risks
and benefits of interventions.
Psychosocial support for those
suffering from wound related
psychological problems (In.gov,
2018).
Pain associated with
wounds can lead to
psychological problems
like anger, anxiety,
depression, stress.
Evaluation of patient
learning and reduced
psychological stress in
patients with delayed
wound healing.

Reference List
Dorai, A. A. (2012). Wound care with traditional, complementary and alternative medicine. Indian journal of plastic surgery: official
publication of the Association of Plastic Surgeons of India, 45(2), 418.
In.gov. (2018). Cite a Website - Cite This For Me. In.gov. Retrieved 7 January 2018, from
https://www.in.gov/isdh/files/Skin_Integrity_Guidelines_T2.pdf