In care plan following is required relevant to Australia:
Nursing Problems:
Four nursing diagnostic statements need to be identified and listed in order of priority.
Expected Outcomes:
You will need to write one expected outcome for each nursing diagnostic statement
identified.
Nursing Interventions:
Four nursing interventions for each nursing diagnostic statement need to be identified.
Scientific Rationales:
A scientific rationale needs to be provided for each nursing intervention. Each rationale
will relate to,nsupport and provide validity for the intervention. Each rationale is to be
referenced.
Handover of Care:
You will need to provide a handover of care for each identified nursing diagnostic
statement usingnISOBAR.
Discharge Plan:
You will need to include a discharge plan for each identified nursing diagnostic
statement.
Care plan: Pressure Ulcer
a) Nursing diagnosis: Impaired Tissue integrity related to friction, shear, and compression
pressure, which causes mechanical destruction of tissue.
Expected outcome:
Patient regains skin integrity on the skin surface
Patient reports reduced pains sensation at the site of impaired skin tissue
Patient understands care plan to prevent re-injury of the site
Nursing interventions Scientific rationales
- Assess the site of the impaired skin to
determine the specific aetiology - Determining the extent of skin impairment/
classification of the pressure ulcers - Monitor skin impairment to check for
swelling, redness, change of colour, pain
intensity or any other indicators of infection - Understanding the aetiology is critical to identify
the appropriate nursing intervention. - To identify if the skin impairment is Stage or Stage
II, III or IV - This systematic inspections is important in early
detection of impending associated health care
complications
Care plan- Pressure Ulcer 2
4.Monitor Patient skin care practices to identify
the appropriate and inappropriate skin practices
(Lewis, 2014)
- Individualize care plan based on patient needs
and preference - Teach patient and family on strategies to
manage the impaired skin - To identify the type of cleaning agents used, water
temperature, and skin cleansing frequency - Holistic care will help predict and prevent pressure
ulcers in the future. - This will help reduce future pressure ulcers
b) Nursing diagnosis: Impaired physical mobility related mobility restrictions associated
with the loss of motor control and deconditioned status
Expected outcome:
Improve patient physical activity
Patient to meet the mutual defined goals that improve patient mobility
Patient verbalizes increased strength and movement ability
Patient is taught how to use adaptive equipment to increase mobility
Nursing interventions Scientific rationales
NIC labels suggested
Exercise therapy: Joint mobility and
ambulation
Improved positioning
- Screen patient mobility ability as follows:
a) Bed mobility
b) transition movements for example from sit
to stand and sitting down again
c) supported and unsupported movements
e.g. walking and standing
2.Monitor client to determine the exact cause
for the impaired mobility to know if they are
they physical or psychological factors (Jaul,
Patient advised to change their position
every 20 minutes, or if confined to bed; once
every two hours to release further pressure
and give the wound a good chance to heal.
The screening patient mobility skills is
important as it allows the nursing staff to
integrate movements exercises in the routine
customary care (Jaul, 2013)
- Some patients refuses to move due to
psychological issues such as depression or
poor coping strategies
Care plan- Pressure Ulcer 3
2014)
- Treat pain using therapeutic interventions.
Apply interventions to improve patients
coping strategies - Consult physical therapist for more
evaluation on gait training, strength training
as they are effective in the rehabilitation of
the clients (Stafford & Brower, 2012) - Monitor patient’s client ability to tolerate
activity using all four extremities - Teach client and carer givers to work
together with the clients when performing
daily activities - Pain causes limitation of movement as
movement exacerbates pain. Hopelessness
and despair may make patient not move - These techniques have been found to be
effective in improving patient coordination
and balance. - Any activity intolerance noted must be
addressed - Using a series of activities can
effectively modify patient attitudes towards
mobility
c) Nursing diagnosis: Imbalanced nutrition more than what is required by the body related
to patient’s poor appetite.
Expected outcome:
Patient indicates tolerance to dietary requirements
Patient body weight and body mass retained within the normal range
Patient reports adequate energy levels
Patient describes the influence of nutrition in prevention of infection
Nursing interventions Scientific rationales
- Teach and establish a plan meal with the
patient which will ensure patient ears
regularly - Patient family and relatives requested to
support the patient by giving her food from
home (Suttipong & Sindhu, 2011) - Maintain high carbohydrate, proteins and
vegetables - Monitor patients laboratory values e.g.
- To ensure the patient learns to balance the
intake of food. - Patients may prefer to eat home food and
may improve patient appetite thus
improving their nutritional intake (Guihan et
al., 2016) - Proteins, carbohydrates and vegetables are
required during treatment - Determining the deficiencies, glucose
Care plan- Pressure Ulcer 4
albumin, blood glucose, Hb blood, haemoglobin associated with delayed
healing (Matsuo, Oie & Furukawa, 2013)
d) Nursing diagnosis: High risk for infection in the pressure ulcer wound related to
exposure to germs
Expected outcome:
Patient is relieved from symptoms infection
Patients white blood cell count remains within the normal range
Patient demonstrates appropriate care for the area prone to infection
Patient indicates meticulous body hygiene by the time the patient is discharged
including handwashing, cutting long nails, and daily baths
Nursing interventions Scientific rationales
- Monitor and report indicators of infection
including discharge from the infected site,
redness and fever - Assess temperature for neutropenic
patient after every 4 hours (Sobotka &
Meguid, 2010) - Monitor laboratory values including
serum protein, cultures, serum albumin and
white blood cells (Singh, Dhayal, Sehgal &
Rohilla, 2015). - Advice of fluid intake
- Onset of infection of the pressure ulcer
activates the immune system and signs of
infection appear - Neutropenic patients may not present
inflammatory response, thus fever is the first
indicator of infection - Laboratory values provide useful insights
of the patients’ immune function which is
helpful when designing patient care plan. - High intake of fluid is important so as to
replace fluid lost during fever (Schols, 2010)
Care plan- Pressure Ulcer 5
- Encourage patient for adequate rest to
boost her immune system - Teach patient and the care giver proper
hygiene technique such as washing hands,
keeping nails short, wearing clean clothes - Physical and emotional stress lowers
patients’ immune function - Consistent and meticulous hygiene is
important factor in reducing the frequency
for nosocomial infections
e) Nursing diagnosis: In effective therapeutic regimen management related to inadequate
knowledge to disease aetiology and management practices.
Expected outcome:
Patient explains the disease, understands treatment and recognizes the need for
medication
Patient demonstrates the need to incorporate the taught health regimen into her
lifestyle
Patient states the ability to cope with the current health situation and improve her
quality of life
Nursing interventions Scientific rationales
- Monitor patient’s readiness and ability to
learn (mental acuity, hearing or sight deficits,
language barriers, cultural barriers etc. - Assess patients knowledge and skills
related to pressure ulcers and influence their
willingness to learn - Patients sensory, physical, and psychosocial
changes may impair patients ability and readiness
to learn - Assimilation of the new information into
existing information will need some negotiation
and stalling.
Care plan- Pressure Ulcer 6
- Assess patients family/care giver support
and need for assistive daily living equipment - The patient is educated to reposition
herself, that help people to reposition, and
use of specialised mattress such as foam
mattress pad, air-filled mattress and special
cushions - Social support improves success patients ability
to adopt the new lifestyle recommended - This is especially important to protect the
patients bony region (Singh, Dhayal, Sehgal &
Rohilla, 2015)
HANDOVER OF CARE
Identity: Jane Candy, UR 124512, under medical ward 9A, bed 24
Situation: Mrs Sophie is admitted at ward 9A. She is 45 y/o and diagnosed with Grade 2
pressure ulcer on her sacrum. She was admitted this morning to manage the pressure ulcer
and weight. Her BMI is 43.7 kg.m 2 .
Background: Mrs Sophie is single and works as a part –time IT, but she is currently on sick
leave. Her appearance is unkempt as she is wearing stained clothes. She has offensive odour,
halitosis and her foot wear is inappropriate. She has impaired mobility and requires assistive
devices for mobility (using a wheelchair). Her current medication includes Paracetamol 1g
orally administered, and Avapro 300mg daily. The reason for seeking medical attention is to
manage an ulcer on her sacrum. The patient says that she has gained weight lately, which
makes it difficult to move as it exacerbates the ulcer pain. Thus, she prefers to spend the
whole day resting as it is comfortable. She has a poor feeding habit as she says that she feeds
on lots of canned food and lots of soft drinks.
Care plan- Pressure Ulcer 7
Assessment: The patient seeks medication attention to manage an ulcer on her sacrum. The
pressure ulcer is Grade 2 and has partial loss of skin on the sacrum. The patient is
overweight with BMI of 43.7 kg.m 2 ,which indicates that she is obese.
Recommendation: To manage pressure ulcer the patient should be given the following
medication:
Ibuprofen 800mg daily to manage pain especially before debridement and dressing
procedures as needed
Diazepam 10 mg three times a day to be for muscle relaxants to prevent muscle spam
as needed
Metronidazole tablets 400mg after 8 hours to manage bacterial infection for seven
days
Cleaning of the wounded site should be done to reduce the rates of infection. Cleaning
should be done using saline solution every time dressing is changed. Dressings must be
applied in order to keep the wound moist and prevent infection. Dressing choice
recommended are those made with gels because they are moisture retentive. The pressure
ulcer debridement should be done using autolytic debridement. The patient is scheduled to
meet a dietician to promote healthy diet. The patient is advised to increase in fluid intake,
foods rich in vitamins and minerals. The patient should also be given dietary supplements
Vitamin C and Zinc. The care plan should be followed in order to improve patient coping
strategies (Skipper, 2010).
Additionally, the patient knowledge skills related to the disease should be assessed. This
is because the previous knowledge, cultural barriers, language barriers and myths influence
Care plan- Pressure Ulcer 8
patient lifestyle and their willingness to adopt a new lifestyle. The patient, family or care
giver should be educated on preventive measures such as frequent repositioning, use of foam
mattress pad, air-filled mattress and special cushions. This will ensure that the patient
healing is holistic (Singh, Dhayal, Sehgal & Rohilla, 2015).
Care plan- Pressure Ulcer 9
DISCHARGE PLAN
Date &
sign
Nursing diagnostic
statement
Target
date
Nursing intervention and outcome Date
achieved
- Impaired Tissue integrity
related to friction, shear and
compression pressure which
causes mechanical
destruction of tissue. - Impaired physical mobility
related mobility restrictions
associated with the loss of
motor control and
deconditioned status - Imbalanced nutrition more
than what is required by the
body related to patient’s poor
appetite. - High risk for infection in
the pressure ulcer wound
related to exposure to germs - In effective therapeutic
regimen management related
to inadequate knowledge to
disease aetiology and
management practices. - Skin Care: Patient/ care giver should clean
the skin as soon as it gets soiled. The patient
should use absorbent pads and skin moisturizer
to control skin moisture. Patient should avoid
massaging bony points (Doley, 2010). - Mobility: Consult physical therapist for more
evaluation on gait training, strength training as
they are effective in the rehabilitation of the
clients (Biesalski, 2010). - Nutrition: Appropriate nutrition is important
for healing. Patient should eat balanced diet as
directed by the dietician. Patient should take
vitamin and mineral supplements as directed by
the doctor. Patient should take 8 glasses of water
each day, and avoid caffeinated drinks, sugary
drinks and alcohol (Cai, Rahman & Intrator,
2013) - Dressing changes: Patient/care giver to start
by washing their hands with antibacterial soap.
Clean the ulcer using saline water and a clean
cloth once a day and use a new gel to dress.
Keep off pressure on the ulcer by using special
mattresses and chair cushion. Change sitting or
sleeping position every 15 minutes and two
hours respectively. - Warning signs: Patient should report to the
clinic immediately if there is increased redness,
soreness, chills, fever or odorous discharges
(Demarre et al., 2014)
_________________________Patient/Significant other signature
Care plan- Pressure Ulcer 10
______________
RN signature
Care plan- Pressure Ulcer 11
References
Biesalski, H. (2010). Micronutrients, wound healing, and prevention of pressure ulcers.
Nutrition, 26(9), 858.
Demarre, L., Verhaeghe, S., Van Hecke, A., Clays, E., Grypdonck, M., & Beeckman, D.
(2014). Factors predicting the development of pressure ulcers in an at-risk population
who receive standardized preventive care: secondary analyses of a multicentre
randomised controlled trial. J Adv Nurs, 71(2), 391-403.
Guihan, M., Murphy, D., Rogers, T., Parachuri, R., SAE Richardson, M., Lee, K., & Bates-
Jensen, B. (2016). Documentation of preventive care for pressure ulcers initiated during
annual evaluations in SCI. The Journal of Spinal Cord Medicine, 160204031040002.
Jaul, E. (2013). Cohort study of atypical pressure ulcers development. International Wound
Journal, 11(6), 696-700.
Jaul, E. (2014). Multidisciplinary and comprehensive approaches to optimal management of
chronic pressure ulcers in the elderly. Chronic Wound Care Management and Research,
Lewis, R. (2014). Reducing harm from pressure ulcers. Nursing Standard, 29(12), 74-74.
Matsuo, M., Oie, S., & Furukawa, H. (2013). Contamination of blood pressure cuffs by
methicillin-resistant Staphylococcus aureus and preventive measures. Irish Journal of
Medical Science, 182(4), 707-709.
Pressure Ulcers: Victims Of ImmobilizationPressure Ulcers: Victims Of Immobilization.
(2012). The Internet Journal Of Surgery, 28(2). http://dx.doi.org/10.5580/2b0f
Care plan- Pressure Ulcer 12
Schols, J. (2010). Protein leakage from pressure ulcers: Clinically relevant? Nutrition, 26(9),
859-860. te Antimicrobial Properties
of Platelet Rich Plasma and Source of Colonization in Pressure Ulcers in Spinal Injury
Patients. Ulcers, 2015, 1-7.
Skipper, A. (2010). Challenges in Nutrition, Pressure Ulcers, and Wound Healing. Nutrition
in Clinical Practice, 25(1), 13-15.