USA: +1 798799211 or +1710200943 
Sign in
Patient: Elderly adult patient at risk for pressure injury
Nursing Diagnosis (NANDA): Impaired Physical Mobility, Risk for Skin Integrity Impairment, and Potential for Infection.
Objectives/Outcomes:
Develop a nursing CARE PLAN for an older adult at risk for pressure injury using wellness and North American Nursing Diagnosis Association (NANDA) diagnoses.
1. The patient will maintain skin integrity without the development of a pressure injury or infection over the next 48 hours as evidenced by intact skin without lesions or discoloration.
2. The patient will demonstrate increased mobility through independently completing bed transfers with minimal assistance within 24 hours as evidenced by completion of one successful transfer with less than moderate amount of assistance from nursing staff.
3. The patient will demonstrate reduced risk of developing an infection within 48 hours as evidenced by a decrease in vital signs to within normal range and absence of symptoms associated with infection (e.g., fever).
Interventions:
1. Maintain adequate nutrition and hydration by providing balanced meals 3 times per day along with snacks as needed; monitor fluid intake and output every 8 hours; provide nutritional supplements such as Ensure Plus if indicated (American Dietetic Association 2009).
2. Monitor skin integrity daily including visual inspection, palpation and use of moisture meters; reposition client every two hours when in bed using appropriate turning protocol based on individualized assessment like Braden scale (Kilcullen et al., 2011); avoid constrictive clothing or devices that could limit circulation near areas prone to pressure injuries (EPUAP 2018). 3. Promote physical activity through walking or other exercises that can be done safely depending on individual’s condition; consider use assistive device(s) if necessary for safe ambulation (CDC 2016).
4 .Provide thorough hand hygiene before each interaction with client and perform contact precautions appropriately when applicable according local protocols; observe any signs/symptoms indicative of infection such as fever, chills, abdominal pain, etc.; report any changes promptly to attending physician and initiate appropriate measures according to hospital policy (CDC 2017). 5 .Educate family members about the importance self-care techniques such proper positioning while sitting/lying down, monitoring diet quality and quantity intake regularly, engaging in low impact exercise programs suited their condition whenever possible—all which contribute maintaining good overall health status thereby reducing risk potential complications like infections due weakened immune system associated aging process itself.(Mayo Clinic 2020)
2. The patient will demonstrate increased mobility through independently completing bed transfers with minimal assistance within 24 hours as evidenced by completion of one successful transfer with less than moderate amount of assistance from nursing staff.
3. The patient will demonstrate reduced risk of developing an infection within 48 hours as evidenced by a decrease in vital signs to within normal range and absence of symptoms associated with infection (e.g., fever).
Interventions:
1. Maintain adequate nutrition and hydration by providing balanced meals 3 times per day along with snacks as needed; monitor fluid intake and output every 8 hours; provide nutritional supplements such as Ensure Plus if indicated (American Dietetic Association 2009).
2. Monitor skin integrity daily including visual inspection, palpation and use of moisture meters; reposition client every two hours when in bed using appropriate turning protocol based on individualized assessment like Braden scale (Kilcullen et al., 2011); avoid constrictive clothing or devices that could limit circulation near areas prone to pressure injuries (EPUAP 2018). 3. Promote physical activity through walking or other exercises that can be done safely depending on individual’s condition; consider use assistive device(s) if necessary for safe ambulation (CDC 2016).
4 .Provide thorough hand hygiene before each interaction with client and perform contact precautions appropriately when applicable according local protocols; observe any signs/symptoms indicative of infection such as fever, chills, abdominal pain, etc.; report any changes promptly to attending physician and initiate appropriate measures according to hospital policy (CDC 2017). 5 .Educate family members about the importance self-care techniques such proper positioning while sitting/lying down, monitoring diet quality and quantity intake regularly, engaging in low impact exercise programs suited their condition whenever possible—all which contribute maintaining good overall health status thereby reducing risk potential complications like infections due weakened immune system associated aging process itself.(Mayo Clinic 2020)
References:
American Dietetic Association 2009 Nutrition Care Manual https://www2.nutritioncaremanual.org : accessed May 6th 2020.
Centers for Disease Control & Prevention CDC 2016 Prevention Strategies for Pressure Injury Development retrieved from https://wwwcdcgov/vitalsigns/pressureulcershtml : accessed May 6th 2020.
Centers for Disease Control & Prevention CDC 2017 Hospital Acquired Infections HAI among Older Adults retrieved from
English
Arabic
Chinese (Simplified)
Chinese (Traditional)
Danish
Dutch
French
German
Italian
Korean
Portuguese
Russian
Spanish
Swedish