Date & Time A U G U S T

Cues

Need

Nursing Diagnosis

Objectives of Care

Nursing Interventions

Evaluation

Subjective: N Objective: a) Limited range motion b) Left upper of U T R I T I O N A L M E T A B O L I C

Risk for impaired skin integrity related to physical immobility secondary to Spinal Cord Injury

That within 2 days span of nursing care, the patient will be able to maintain skin

1. Assess skin routinely, noting moisture, color and turgor. R: This may indicate presence of impairment of the skin. 2. Observe for reddened or blanched areas or skin rashes. R: To monitor likelihood of progression of skin breakdown 3. Provide proper positioning such as turning to sides every 2 hours R: To prevent shear injury in the skin 4. Provide protection by use of pads, pillows, foam mattress, or water bed R: To increase circulation and limit excessive tissue

August 15, 2011 @ 2 PM GOAL MET After 2 days span of nursing care, the patient was able to maintain skin integrity as evidenced by: a. elevated frequently upper and lower extremities as tolerated b. patient was turned to sides every 2 hours c. absence of bedsore and redness over bony prominences

Rationale: Pressure ulcers may be caused by inadequate blood supply and resulting reperfusion injury when blood re-enters tissue. A simple example of a mild pressure sore may be experienced by healthy individuals while sitting in the same position for extended periods of time: the dull ache

integrity as evidence by: a. Absence of redness over bony prominenc es b. Absence of bedsore. c. Intact skin

10,

arm fracture c) Senile skin

2 0 1 1

turgor d) Needs assistance in moving

such as: @ - sitting 8 transferring to A M wheelchair e) Prolonged bed rest

experienced is P A T T E R N indicative of impeded blood flow to affected areas. Within hours, this shortage of blood supply, called ischemia, may lead to tissue damage and cell death. The sore will initially start as a red, painful area, which eventually turns purple. Left untreated, the skin may break open. Moist skin is more sensitive to tissue ischemia and necrosis and is also more likely to get infected. Immobility, which leads to pressure, shear, and friction, is the factor

pressure 5. Assist patient in transferring to wheelchair to shift position R: Frequent position changes prevent pressure areas from developing. 6. Provide patient adequate nutritional/fluid intake R: To maintain general good health and skin turgor. 7. Encourage frequent elevation of extremities when sitting or at bed rest R: To enhance venous return and reduce edema formation 8. Reinforce the importance of mobility, turning, or ambulation in prevention of pressure ulcers. R: Teaching the patient methods to prevent pressure ulcers will enhance their

most likely to put an individual at risk for altered skin integrity.

sense of self- efficacy and can improve compliance with the prescribed interventions.