KEISER COLLEGE Melbourne, Florida

Individual Nursing Care Plan

Nursing Diagnosis Statement #3: Risk for Impaired Skin Integrity R/T Physical Immobilization, Mositsture,
Pressure and Shearing Forces, Skeletal Prominence

NURSING
DIAGNOSIS
STATEMENT

GOALS

INTERVENTIONS

RATIONALE(S)

Nursing
Diagnosis
Statement #3:

LONG TERM
GOAL:

1-1.
Access skin over bony
prominences and other
pressure point for signs
of redness, breakdown,
or trauma every day by
0930.

1-1.
Proper and thorough skin
surveillance reduces and
prevent formation of
pressure ulcers, (Berman
& Snyder, 2012, p. 921).

1-2.
Perform pressure relief
techniques: floating heels,
position client 15-30o side
lying angle with pillow
supports every 2 hours.

1-2.
Pressure Ulcers can be
prevented through proper
positioning techniques,
(Berman & Snyder, 2012,
p. 921).

1-3.
Apply Skin-Prep to
bilateral heels, coccyx, and
areas of suspected
pressure every day by
0930.

1-3.
Skin-prep helps prevent
and provides a barrier of
protection against friction
and shearing of skin,
(Berman & Snyder, 2012,
p. 940).

2-1.
Check client for

2-1. Moisture supports

growth of bacterial

Risk for
Impaired Skin
Integrity R/T
Physical
Immobilization,
Moisture,
Pressure and
Shearing Forces,
Skeletal
Prominence
Level of
Maslow's
Hierarchy:

Client will have

intact skin while in
Long Term Care.
1. SHORT TERM
GOAL:
Client will not have
any reddened areas
over bony
prominences or
other pressure
points for next 3
months.

SAFETY

2. SHORT TERM

Individual Nursing Care Plan

Page _2_ of _2_

IMPLEMENTATION
Off-loaded pressure;
07/15/15 (1030) Floated pts
heels; positioned 15o on R side,
pillow to support back
07/16/15 (1015 Floated pts
heels; positioned 15o on L side,
pillow to support back
07/22/15 (1010): Floated pts
heels; positioned 15o on L side,
pillow to support back

EVALUATION

Goal #1:
Goal met,
No reddened
pressure areas,
Continue with care
plan.

Inspected pts areas of pressure

(bilateral: heels, toes, knees,
elbows, and scapulae; bony
regions: coccyx & rear of head).
No reddened, non-blancheable
areas found.
07/15/15 (0900),
Applied skin prep to bilateral
heels and elbows, also to coccyx
prior to dressing patient.
07/16/15 (0815): Applied skin
prep to bilateral heels and
elbows, also to coccyx prior to
dressing patient.
07/22/15 (0830):
Applied skin prep to bilateral
heels and elbows, also to coccyx
prior to dressing patient.
07/15/15 (1030) checked client

Goal #2:

KEISER COLLEGE Melbourne, Florida

Individual Nursing Care Plan
Nursing Diagnosis Statement #3: Risk for Impaired Skin Integrity R/T Physical Immobilization, Mositsture,
Pressure and Shearing Forces, Skeletal Prominence
GOAL:
Clients skin will be
clean and dry for
next 30 days.
.

incontinence q 2 hrs.
beginning in morning with
dressing
2-2.
Apply barrier cream after
each episode of
incontinence
2-3.
Avoid drying cleansers
when providing personal
hygiene.

Individual Nursing Care Plan

microorganisms.
,(Berman & Snyder, 2012,
p. 765).
2-2.
Barrier cream prevents
skin breakdown from
constant moisture
exposure. (Berman &
Snyder, 2012, p. 1306).
2-3.
Soap irritates skin if not
completely removed or if it
is too harsh, (Berman &
Snyder, 2012, p. 771).

Page _2_ of _2_

for incontinence
07/16/15 (1015) checked client
for incontinence
07/22/15 (1010): checked client
for incontinence

Goal met
Client is remaining
clean and dry
Continue with POC

07/15/15 (0900),

Applied barrier cream to coccyx

07/16/15 (0815):
Applied barrier cream to coccyx
07/22/15 (0830):
Applied barrier cream to coccyx
07/15/15 (0900),

When washing used mild soap

and rinsed, dried completely
07/16/15 (0815):
When washing used mild soap
and rinsed, dried completely
07/22/15 (0830):
When washing used mild soap
and rinsed, dried completely