Nursing diagnosis ad planning related to skin integrity and wound care-Unit 2 – Flashcards
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Which nursing diagnoses are appropriate for a patient with a wound?
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Impaired Skin Integrity Imbalanced Nutrition Disturbed Body Image Knowledge Deficit
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A visiting nurse is performing an initial assessment on an older adult male recently released from the hospital after open heart surgery. The patient has a history of Type II diabetes and is a widower. His children and family all live out of state. The nurse performs a thorough physical examination. Although the patient's chest incision appears to be healing normally, the nurse notices an unhealed pressure ulcer on the patient's right toe. What objective data can the nurse collect?
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Presence of wound on toe. History of type 2 diabetes. Healing incision on chest.
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Which is a nursing diagnostic statement related to skin integrity and wound care?
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Impaired Physical Mobility related to pain during position changes, as evidenced by the patient's grimacing when turned in bed.
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Nurse Role in Delegation
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Assessing and evaluating a patient's skin and wounds; this task cannot be delegated Reassessing and evaluating treatment plan efficacy Decision-making about what can and cannot be delegated to unlicensed assistive personnel (UAP), other health care workers, or family members Supervising UAP Enforcing facility policy and scope of practice guidelines
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Nurse Role in Collaboration
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Decision-making about when to collaborate with a wound care or incontinent specialist for at-risk patients
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UAP Collaboration Considerations
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Reporting to the nurse any changes in patient skin condition or integrity, elevation in temperature, complaints of pain, increased wound drainage or incontinence, or observed changes in dietary intake Performing limited dressing changes, depending on the setting and treatment Application of non-sterile dressings for chronic wounds with an established treatment plan in place
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Collaboration Participants
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Surgeon Infectious disease provider Physical and occupational therapy Social worker and/or discharge planner Nutritionist Wound care specialist (including skin care products and cost containment measures) Incontinent specialist Burn care/rehabilitation specialist
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Families Delegation Considerations
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Providing skin hygiene other than care of wounds/pressure ulcers Assisting with oral hygiene Providing hair care/shaving Assisting with turning or repositioning as deemed safe by the nurse
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Families Collaboration Considerations
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Decision-making about purchasing of supplies for home wound care Selecting products based on insurance coverage/financial concerns Performing home care procedures, such as wound care, burn care, and dressing changes
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Goals short term
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Patient will create a nutrition plan, in consultation with the nutritionist, within 1 week. Patient will meet with social worker within 1 week. Patient will consult with wound specialist within 72 hours. Patient will implement appropriate wound care procedures within 72 hours. Patient will show signs of wound healing, as evidenced by granulation tissue in the wound within 1 week. Patient will state strategies to promote wound healing following patient education.
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Goals long term
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Patient will implement a nutritional meal program.
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Outcomes
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Patient regains 5 lbs. Patient demonstrates no evidence of additional pressure ulcers.
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Which nursing action is an example of collaboration?
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Making a decision as to when to call a wound care specialist
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Which tasks can UAP perform in regard to skin integrity and wound care?
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Reporting to the nurse any changes in patient skin condition or integrity. Application of non-sterile dressings for chronic wounds with an established treatment plan in place.
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Which tasks can be delegated to a family member in regard to skin integrity and wound care?
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Assisting with hair care
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Which goals are examples of goals related to skin integrity and wound care?
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Patient will participate in position changes within 24 hours. Patient will show signs of wound healing, as evidenced by presence of granulation tissue in the wound within 1 week. Patient will remain free of infection during hospitalization. Patient will show acceptance of the change in body image by helping with dressing change within 48 hours.
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Which goal is an example of a long-term goal related to skin integrity and wound care?
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Patient will implement a nutritional meal program.
