NURSING CARE PLAN on Impaired Skin Integrity

Nursing Diagnosis: Delayed wound recovery due to ineffective therapeutic regimen management and self-care deficit as
evidenced by low self-esteem and impaired physical mobility.

Goals Expected Outcomes Nursing Interventions Implementation Evaluations

After the process The patient are 1. Discuss pain control measures if needed. Patient will be
the patient will: expected to: • To help patient coop towards the assist at least twice
proper pain management thus a day observing on
1. Have a good • Know the minimizing pain suffering and the wound condition
and healthy causes of ways of treating them. and any observable
skin condition. his/her changes.
condition and 2. Discuss Importance of adequate nutrition
2. Be able to follow steps on (especially fluids, proteins, vitamins B and Will be repositioned
coop with the the proper C, iron and Calories). on bed at least
activities of therapeutic three times a day,
Daily Living • These provide patient information from 6am – 12pm –
management. how nutrition could elevate his
(ADL) and will 6pm.
function chances of a faster recovery and
normally. • Be confined for wound healing. There will be a
bed rest for change of shift
3. Have a proper about 2-3 3. Demonstrate appropriate positions for report twice a day
and effective weeks or more pressure relief. necessary to obtain
therapeutic with controlled • Enable client to minimize further an update.
management mobility on the skin trauma thus promoting wound
of such affected part, healing and establish physical Record every vital
conditions. that is towards mobility. and observable
recovery. signs or changes
4. Be 4. Establish a turning or repositioning within the patient
knowledgeable • Within 24 hours schedule and entire unit.
of such or less the • This provide patient’s a guide
conditions and patient can towards a proper skin management
the ways of express feeling technique minimizing more skin
treating and of relief and trauma and also giving the patient
preventing satisfaction something to do thus promoting
them. upon the self-esteem.
treatment of his 5. Instruct in wound assessment and
condition. provide mechanism for documenting
• Necessary to gather more data
concerning the patient’s condition
thus identifying skin problems
clearly and promoting self-esteem.
• Fully recover
within a month 6. Emphasize principles of asepsis,
of continued especially hand washing and proper
therapy and methods of handling used dressings.
retain self- • To avoid possible infection thus
esteem. hindering the wound healing
process.

7. Provide information about signs of wound

infection and order complications to report.
• Elevate the chances of faster wound
healing which is important towards
avoiding further complications or
early detections that requires
immediate interventions.

8. Demonstrate wound care technique such

as wound cleansing and dressing changing.
• To provide the patient on the
correct procedures and techniques
of wound caring.

9. Identify potential sources of skin trauma

and means of avoidance.
• Necessary to anticipate future
events thus avoiding unexpected
complications or changes vital to
the patient’s condition.

10. Support the use of appropriate defense

mechanism.
• To asses patient upon the proper
management of stress or
depressions concerning on his
condition.

11. Encourage verbalization of feelings,

perceptions and fears.
• To evaluate patients perceptions
upon his condition and giving us
information towards assessing client
problems.