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The nursing diagnoses include impaired skin integrity, risk for impaired nutrition intake, and risk for infection. Supporting data includes an ulcer on the coccyx, skin tear on the right hand, Foley catheter, low hemoglobin, consult for nutrition therapy, and soft texture diet. Goals are for the client to experience healing of pressure ulcers with pressure reduction, remain free of infections, and display sufficient nutritional ingestion. Interventions include assessing wounds, positioning, monitoring vitals and labs, and implementing asepsis during dressing changes.

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Savanna Chambers
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70 views2 pages

Concept Map Template

The nursing diagnoses include impaired skin integrity, risk for impaired nutrition intake, and risk for infection. Supporting data includes an ulcer on the coccyx, skin tear on the right hand, Foley catheter, low hemoglobin, consult for nutrition therapy, and soft texture diet. Goals are for the client to experience healing of pressure ulcers with pressure reduction, remain free of infections, and display sufficient nutritional ingestion. Interventions include assessing wounds, positioning, monitoring vitals and labs, and implementing asepsis during dressing changes.

Uploaded by

Savanna Chambers
Copyright
© © All Rights Reserved
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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Note: NO identifiable resident information should be included Student: Savanna Chambers Date: March 13th, 2017

Nursing Diagnosis # Impaired Skin Integrity Nursing Diagnosis # Risk for Impaired Nutrition Intake

*Supporting Data: ulcer located on coccyx, skin tear on rt hand, Foley *Supporting Data: consult for nutrition therapy, skin tear, ulcer located on
catheter, low hemoglobin coccyx, TwoCalHN after meals, soft texture diet

Diagnosis:

Medical History:

Allergies:
Code Status: DNR Level B

Nursing Diagnosis # Risk for Infection Nursing Diagnosis #

*Supporting Data: foley catheter, ulcer located on coccyx, rt handed skin tear
*Supporting Data:

*This should support the nursing diagnosis and may include assessment data such as: interview data, direct/indirect observation, physical assessment,
medical records review, and analysis and synthesis of available laboratory and other diagnostic studies (Gulanick & Myers, 2017, p 3)
Note: NO identifiable resident information should be included Student: Savanna Chambers Date: March 13th, 2017

Nursing Diagnosis # Impaired Skin Integrity Nursing Diagnosis # Risk for Infection

Goal: Client will experience healing of pressure ulcers and experiences Goal: Client will remain free of local or systemic infections, as evidenced by
pressure reduction. the absence of foul-smelling wound exudate.

Interventions:
Interventions:
1. Assess client’s temperature
1. When changing dressing assess for color, odor, exudate, bleeding and
tissue surrounding ulcer 2. Monitor clients WBC count
2. Assess for urinary/fecal incontinence q2h 3. Implement surgical asepsis when changing wound dressing to prevent
3. Turn and position q2h from side to side
introduction of microorganisms
Evaluation:

Evaluation:
Nursing Diagnosis # Risk for Impaired Nutritional Intake Nursing Diagnosis #
Goal:
Goal: Patient displays nutritional ingestion sufficient to meet metabolic needs
as manifested by stable weight or muscle-mass measurements Interventions:
Interventions: 1.
2.
3.
1. Assess for physical signs of poor nutritional intake
2. Note clients eating habits and environment Evaluation:

3. Monitor blood tests

Evaluation:

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