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NCP

This document summarizes a nursing care plan for a client with impaired skin integrity due to abrasions and wounds from a vehicular accident. The plan involves daily inspection of wounds, promoting nutrition, rest, and mobility to aid healing. Anti-infective drugs and aseptic technique are used to prevent infection while the client learns to care for the wounds and report any changes in their condition. After two days some improvement was seen with less redness and the client following recommendations to promote healing.

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TrishaYsobelleMedianteMorales
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6K views

NCP

This document summarizes a nursing care plan for a client with impaired skin integrity due to abrasions and wounds from a vehicular accident. The plan involves daily inspection of wounds, promoting nutrition, rest, and mobility to aid healing. Anti-infective drugs and aseptic technique are used to prevent infection while the client learns to care for the wounds and report any changes in their condition. After two days some improvement was seen with less redness and the client following recommendations to promote healing.

Uploaded by

TrishaYsobelleMedianteMorales
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NCP: Impaired Skin Integrity r/t skin destruction secondary to vehicular accident

Cues Objective: - Abrasion of wounds noted. - redness noted - pain on the affected area - with moist wound noted - Medication: Bactroban ointment Need NUTRITIONAL-METABOLIC PATTERN Diagnosis Impaired Skin Integrity related to skin destruction secondary to vehicular accident. Objectives At the end of span of care our client will be able to demonstrate progressive improvement in wound or lesion healing as evidence by: a. absence of abrasions, moist and redness of the surface of the wound; b. demonstrate behavior/lifestyle changes to promote healing and prevent complications; c. verbalize understanding on condition and causative factors. Interventions 1. note evidence of other organ or tissue involvement. R: to identify causative or contributing factors. 2. assess adequacy of blood supply and innervation of the affected tissue. R: to note the extent of injury.

3. inspect wounds or lesions daily for changes. R: promotes timely interventions/ revision of plan of care. 4. promote good nutrition with adequate protein such as fish. R: to promote faster wound healing. 5. provide adequate periods of rest and sleep. R: to minimize impairment and promote healing. 6. instruct to practice aseptic technique. R: reduces risk of cross contamination. 7. promote early mobility. Provide position changes. R: to promote circulation and prevent excessive tissue pressure. 8. discuss importance of early detection and reporting of changes in condition R: promotes early detection of the developing complication 9. administer anti-infective drugs as ordered. R: to promote wellness. 10. emphasize need for adequate nutritional or fluid intake. R: to involve patient in his own care. Evaluation After 2 days span of care our client was able to demonstrate progressive improvement in wound or lesion healing as evidence by: a. presence of abrasions but minimal redness noted on the surface of the wound; b. demonstrate behavior/lifestyle changes to promote healing and prevent complications; patient was seen guarding behavior on the site

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