Risk of pressure ulcer related to incontinence
Topic: Tissue integrity
Provide the expected outcomes for each of the following Nursing interventions:
Diagnosis: Risk of pressure ulcer related to incontinence
Nursing Intervention, rationale
1. Intervention: Toilet patient every 2 hours
Rationale: To reduce episodes of wetting
Expected outcome:
2. Intervention: Reposition patient every 2hours.
Rationale: Helps keep blood flow and skin to stay healthy to prevent bed sores
Expected outcome:
3. Intervention: Offer frequent fluids and diet to patient
Rationale: To maintain adequate nutrition and hydration
Expected outcome:
4.Intervention: Administer breeze boost supplement as prescribed.
Rationale: To fill nutritional gaps and to prevent skin breakdown.
Expected outcome:
Diagnosis:Impaired tissue integrity related to bruising on lower right abdomen
Nursing Intervention, rationale
5. Intervention: Monitor bruise at least once daily for color changes, redness, swelling, warmth, pain, or other signs of infection
Rationale: Systematic inspection can identify impending problems early.
Expected outcome:
6. Intervention: Administer Certavite-Antioxidant as prescribed
Rationale: This will help fill nutritional gaps in the body to help nourish the skin.
Expected outcome:
7.Intervention: Assess patient’s nutritional status; refer for a nutritional consultation.
Rationale: Inadequate nutritional intake places the patient at risk for skin breakdown and compromises healing, causing impaired tissue integrity.
Expected outcome:
8.Intervention: Monitor patient’s skincare practices, noting the type of soap or other cleansing agents used, the temperature of the water, and frequency of skin cleansing.
Rationale: Individualize plan is necessary according to the patient’s skin condition, needs, and preferences.
Expected outcome:
