1.
Impaired
skin integrity related to full thickness as evidence by destroyed of tissue.
Goal:
Patient will demonstrate tissue regeneration.
|
No.
|
Nursing
Intervention
|
Rationale
|
|
1.
|
Assess the
area of impaired skin integrity.
|
For further
planning.
|
|
2.
|
Monitor site
of skin impairment at least once a day for color changes, redness, swelling,
warmth, pain and other signs of infection.
|
To prevent
complications.
|
|
3.
|
Do dressing
twice per day.
|
Encourage
rehabilitation of skin.
|
|
4.
|
Provide diet
that high in protein.
|
To help build
new cell tissue.
|
|
5.
|
Encourage
patient to take more vegetables and fruits rich in vitamin D such as grapes,
brinjal and purple spinach.
|
To promote
the wound healing.
|
|
6.
|
Select a
topical treatment that will maintain a moist wound-healing environment.
|
To avoid
infection.
|
Evaluation: Patient’s skin
integrity was recovered.
No comments:
Post a Comment