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,
support 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 using
ISOBAR.
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 |
| 1. Assess the site of the impaired skin to determine the specific aetiology 2. Determining the extent of skin impairment/ classification of the pressure ulcers 3. Monitor skin impairment to check for swelling, redness, change of colour, pain intensity or any other indicators of infection 4.Monitor Patient skin care practices to identify the appropriate and inappropriate skin practices (Lewis, 2014) 5. Individualize care plan based on patient needs and preference 6. Teach patient and family on strategies to manage the impaired skin | 1. Understanding the aetiology is critical to identify the appropriate nursing intervention. 2. To identify if the skin impairment is Stage or Stage II, III or IV 3. This systematic inspections is important in early detection of impending associated health care complications 4. To identify the type of cleaning agents used, water temperature, and skin cleansing frequency 5. Holistic care will help predict and prevent pressure ulcers in the future. 6. 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 1. 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, 2014) 3. Treat pain using therapeutic interventions. Apply interventions to improve patients coping strategies 4. Consult physical therapist for more evaluation on gait training, strength training as they are effective in the rehabilitation of the clients (Stafford & Brower, 2012) 5. Monitor patient’s client ability to tolerate activity using all four extremities 6. Teach client and carer givers to work together with the clients when performing daily activities | 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) 2. Some patients refuses to move due to psychological issues such as depression or poor coping strategies 3. Pain causes limitation of movement as movement exacerbates pain. Hopelessness and despair may make patient not move 4. These techniques have been found to be effective in improving patient coordination and balance. 5. Any activity intolerance noted must be addressed 6. 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 |
| 1. Teach and establish a plan meal with the patient which will ensure patient ears regularly 2. Patient family and relatives requested to support the patient by giving her food from home (Suttipong & Sindhu, 2011) 3. Maintain high carbohydrate, proteins and vegetables 4. Monitor patients laboratory values e.g. albumin, blood glucose, Hb | 1. To ensure the patient learns to balance the intake of food. 2. Patients may prefer to eat home food and may improve patient appetite thus improving their nutritional intake (Guihan et al., 2016) 3. Proteins, carbohydrates and vegetables are required during treatment 4. Determining the deficiencies, glucose 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 |
| 1. Monitor and report indicators of infection including discharge from the infected site, redness and fever 2. Assess temperature for neutropenic patient after every 4 hours (Sobotka & Meguid, 2010) 3. Monitor laboratory values including serum protein, cultures, serum albumin and white blood cells (Singh, Dhayal, Sehgal & Rohilla, 2015). 4. Advice of fluid intake 5. Encourage patient for adequate rest to boost her immune system 6. Teach patient and the care giver proper hygiene technique such as washing hands, keeping nails short, wearing clean clothes | 1. Onset of infection of the pressure ulcer activates the immune system and signs of infection appear 2. Neutropenic patients may not present inflammatory response, thus fever is the first indicator of infection 3. Laboratory values provide useful insights of the patients’ immune function which is helpful when designing patient care plan. 4. High intake of fluid is important so as to replace fluid lost during fever (Schols, 2010) 5. Physical and emotional stress lowers patients’ immune function 6. 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 |
| 1. Monitor patient’s readiness and ability to learn (mental acuity, hearing or sight deficits, language barriers, cultural barriers etc. 2. Assess patients knowledge and skills related to pressure ulcers and influence their willingness to learn 3. Assess patients family/care giver support and need for assistive daily living equipment 4. 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 | 1. Patients sensory, physical, and psychosocial changes may impair patients ability and readiness to learn 2. Assimilation of the new information into existing information will need some negotiation and stalling. 3. Social support improves success patients ability to adopt the new lifestyle recommended 4. 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.m2.
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.
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.m2 ,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 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).
DISCHARGE PLAN
| Date & sign | Nursing diagnostic statement | Target date | Nursing intervention and outcome | Date achieved |
| 1. Impaired Tissue integrity related to friction, shear and compression pressure which causes mechanical destruction of tissue. 2. Impaired physical mobility related mobility restrictions associated with the loss of motor control and deconditioned status 3. Imbalanced nutrition more than what is required by the body related to patient’s poor appetite. 4. High risk for infection in the pressure ulcer wound related to exposure to germs 5. In effective therapeutic regimen management related to inadequate knowledge to disease aetiology and management practices. | 1. 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). 2. Mobility: Consult physical therapist for more evaluation on gait training, strength training as they are effective in the rehabilitation of the clients (Biesalski, 2010). 3. 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) 4. 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. 5. Warning signs: Patient should report to the clinic immediately if there is increased redness, soreness, chills, fever or odorous discharges (Demarre et al., 2014) |
References
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, 3.
Lewis, R. (2014). Reducing harm from pressure ulcers. Nursing Standard, 29(12), 74-74. .29.12.74.s63Matsuo, 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).