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Nursing Care Plan: Skin Abrasion

PRNU 105: Professional Practice

Nursing Care Plan

Vancouver Island University

Ainsley Allan
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Nursing Care Plan: Skin Abrasion
Nursing Assessment Nursing Diagnosis Plan and patient goals Implementation Evaluation

(intervention)
Previous medical Impaired skin integrity Patient will have no longer - assess abrasion Q6H for In 14 days, skin integrity:
diagnosis: Diabetes related to weakness in have further skin any notable changes such skin and mucous
Mellitus (type 2) lower extremities as breakdown. As well as as size, colour, swelling membranes intact with no
Objective Data: evident by disruption of reduced redness and and drainage infections/ complications.
BP: 115/75 skin integrity, soreness soreness to affected area Rationale: to decrease risk AEB skin is intact, no
Oxy: 96% and redness to affected of further impaired skin swelling redness and
RR: 16 area. integrity. movement of affected
PR: 67 Smart goal: (Williams and Hopper, area has no pain/
Temp: 36.70 C Time- goal will be met 2015, Pg. 1285) discomfort.
Patient is 100 lbs and within a two-week time
has a height of 5’0. frame. clean abrasion site with
Subjective Data: sterile dressing technique. If goal is not met, a re-
Diabetes causes muscle Rationale: to decrease risk evaluation of skin integrity
weakness causes of infection will be done Including a re-
frequent falls in patient (Williams and Hopper, evaluation of factors
patient concerns are as 2015, Pg. 1285) contributing to a
stated “skin abrasion to compromised heal.
left upper leg” signs -Educating client on best Such as medications,
and symptoms patient hygiene practices with blood flow, proper patient
stated are “redness and impaired skin integrity. education as well as
soreness to left leg” Monitor status of skin proper cleansing of
patient stated 5/10 around abrasion as well as abrasion.
pain scale. monitoring patients skin
care practices noting soap
Assessing appearance type and cleansing
of patient’s skin practices
Noting and swelling, Rationale: to promote
redness, tenderness, healing of wound
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Nursing Care Plan: Skin Abrasion
size and character of (Taylor, Lillis and Lynn,
abrasion the to the 2015, Pg. 980-981)
affected area.

Assessing Recent -Bed rest care to improve

changes of skin and increase mobility to
integrity – noting any patients affected area.
breakdown of skin, the Rationale: to improve
amount of fluids if any patient’s ability to move
without pain
Assessing patients (Taylor, Lillis and Lynn,
Activity and mobility on 2015, Pg. 981)
affected area.

Assessing pulses
especially in lower
extremities

Nursing assessment Nursing diagnosis Plan and patient goals Implementation Evaluation

(Intervention)
Previous medical . Risk for infection related Patient will identify - assess knowledge of In 14 days, skin integrity:
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Nursing Care Plan: Skin Abrasion
diagnosis: Diabetes to diabetes AEB decreased
Mellitus (type 2) circulation of blood flow to
Objective Data:
BP: 115/75
Oxy: 96%
RR: 16
PR: 67
Temp: 36.70 C
Patient is 100 lbs and has a
height of 5’0.
Subjective Data:
Diabetes causes muscle
weakness causes frequent
falls in patient
patient concerns are as
stated “skin abrasion to
left upper leg” signs and
symptoms patient stated
are “redness and soreness
to left leg” patient stated
5/10 pain scale.
Assessing patients Activity
and mobility on affected
area.
Assess use of mobility
assistance equipment
Assessing disease related
symptoms
interventions to
prevent/reduce risk of
affected area taking it infection
longer to heal/ fight
infection.
Smart goal:
patient will heal in a timely
manner with no delays
due to previous medical
diagnosis. Will heal within
a 2-week time span (14
days)
diabetes self-care skin and mucous
Rationale: teaching should membranes intact with no
be initiated if there is a infections/ complications.
knowledge deficit. AEB skin is intact, no
(Williams and Hopper, swelling redness and
2015, Pg. 934) movement of affected
area has no pain/
Implement topical discomfort.
medication rather than PO
medication for abrasion
Rationale: blood flow is If goal is not met, a re-
decreased, and medication evaluation of skin integrity
may be less effective by will be done Including a re-
route of blood to affected evaluation of factors
area. (Williams and contributing to a
Hopper, 2015, Pg. 931) compromised heal.
Such as medications,
blood flow, proper patient
Implement patient to not education as well as
cross legs and avoid proper cleansing of
wearing tight socks and abrasion.
shoes
Rationale: tight socks and
crossing legs may prevent
adequate blood supply to
lower extremities.
Williams and Hopper,
2015, Pg. 932)
Monitor patient’s
temperature every 8 hrs
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Nursing Care Plan: Skin Abrasion
- Assessing s/s with and PRN
diabetes Rationale: an increasing
- Any medications temperature can indicate
infection.
Assessing feet and lower (Williams and Hopper,
extremities, checking feet 2015, Pg. 1309)
pulses, temperature, skin
integrity and pressure Monitor signs and
points. symptoms of systemic
spread of infection such as
hypotension, tachycardia.
Rationale: prevent sepsis
and to be able to actively
track and report if
infection occurs.

(Williams and Hopper,

2015, Pg. 1309)

Monitor patients pain

levels on a 0-10 pain scale.
Rationale: an increase in
pain level may indicate an
infection occurring.
(Williams and Hopper,
2015, Pg. 1309)
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Nursing Care Plan: Skin Abrasion
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Nursing Care Plan: Skin Abrasion
References

Hopper, P. & Williams, L. (2015). Understanding Medical Surgical Nursing. Philadelphia, USA: F.A Davis company.

Lillis, C., Lynn, P. & Taylor, C. (2015). Fundamentals of Nursing. Philadelphia, USA: Wolters Kluwer Health.