Nursing Fundamentals, Essay Example

Nursing Diagnosis

The patient checked showed distinct symptoms of Impaired Skin Integrity. The said case has been related to the emergence of symptoms related to prolonged pressure presented through the redness/discoloration in the skin. This impairment is seen to have a distinct effect on the patient’s skin-integrity.

Patient Goal/Outcomes

To resolve the issues, it is important to eliminate the following factors:

• Pressure redness will heal.
• The Pressure will decrease in size
• Pressure will be relieved
• Patient’s skin will be free of infection

These symptoms could be further lessened through application of cream and other laser interventions making it easier to remove or relieve the pressure hence bringing back the integrity of the skin accordingly.

Interventions

• Complete a thorough skin assessment of all other skin with particular attention to high –risk areas over bony prominences every shift, noting edema with particular attention to sacral heels, and elbows.
• Turn the patient every 2 hours using turn sheets and acceptable patient handling techniques, avoiding friction and shearing force.
• Apply heel and elbow protectors bilaterally. Be sure heals are kept off the surface of the bed be suspending the feet off a pillow or wedge.

References

Thompson Delmar learning. (2008). Medical Surgical Nursing, nursing care plans. Shielda Glover Rogers, RN,PHD