Assessment Diagnosis Planning Intervention Rationale Evaluation

Objectives: Impaired skin After 2 to 3 hours of  Assess skin  Open sores or After 2 to 3 hours of
nursing intervention for lesions; blisters that nursing intervention the
 Presence of
integrity related the patient will be able note color and are form patient will be able to
bollous to trauma or to, presence of located on display improvement in
 (+) Pruritus infection crusting trunk and wound healing as
-Report any altered evidenced by:
 Extremes of extremities.
sensation or pain at
age Ruptured
site of tissue -minimized presence of
 Edema blisters and
impairment wounds
 Itching of the sores may
skin -patient can have yellow -several wounds have
 Local pain demonstrate crusting on or dried up
 Swelling of understanding of plan around the
to heal wound and lesions. -minimized erythema
nearby glands
 Affected area prevent injury -minimized purulent
 Assess vital  Monitor for
hot, tender to signs; note discharged
-can describes signs of
touch fever
measures to protect to systemic -presence of itchiness
 Localized
heal the tissue, infection or may decrease
erythema
including wound care complication.
 Purulent
discharge -patient’s wound
 Disease is
decreases in size and  Maintain spread
has increased contact through direct
granulation tissue. precautions contact with
lesions. Use
 personal
protective
equipment or
(PPE) and
sanitize
equipment or
tools ( or use
disposable
equipment if
available)

 Topical
 Apply topical
antibiotics
antibiotics
may be
with sterile,
appropriate
individual
when a small
applicators
area is
affected. A 7
day course is
generally
required.

 Make sure  Make sure to

patient’s avoid
fingernails contamination
are trimmed of container
and clean and other
areas when
applying
 topical
treatments.

 Itching is a
common
symptom;
scratching
lesions will
cause the
disease to
spread to
other parts of
the body, or
 Educate the other people.
patient and
SO about how  They should
to prevent the use their own
spread of the towels and
disease to linens which
other people. should be
washed alone.
 Ensure good
hand washing
habits
 Avoid contact
with other
people who
may have
depressed
 immune
system.
 Assess for
edema  Skin
tightened
tautly over
edematous
tissue is at
risk for
 Assess the impairment.
amount of
shear  A typical
(pressure cause of shear
exerted is elevating
laterally) and the head of
friction the patient’s
(rubbing) on bed: the
the patient’s body’s weight
skin. is displaced
downward
onto the
patient’s
sacrum.
Typical
causes of
friction
include the
patient
rubbing heels
or elbows
against bed
linen, and
moving the
patient up in
bed without
the use of the
lift a sheet.