Skin Breakdown Nursing Diagnosis

Medications Zinc/HC/Clotrimazole Compounded cream Apply 1 application topically if needed for wound care For topical application to bilateral groin folds, abdominal fold, and left breast PRN to keep all areas protected at all times Wound dressing, topical paste Apply topically 2 times a day Lab Data No lab data pertinent to diagnosis Education 1. Troy BSN Student will teach patients son to how to safely reposition the patient to relieve pressure from bony prominences. 2. Troy BSN Student will teach the client to use pillows or foam wedges to prevent pressure injury. 3. Troy BSN Student will educate the patient on causes of skin breakdown, Pathophysiology Skin breakdown and tissue ischemia can lead to the development of pressure injuries, previously called pressure ulcers or bed sores. There are four stages of pressure ulcers which are categorized according to the depth of tissue involvement. Stage 1 pressure ulcers involve persistent redness and irritation of the skin. In Stage 2 there is loss of skin in the epidermal or dermal layers. In Stage 2 ulcers show deterioration of the epidermis, dermis, and deeper layers of subcutaneous tissue. And lastly, Stage 5 ulcers show loss of full thickness of tissue down to the fascia, muscle, and bone. (Capriotti & Frizzell, 2016, p. 69). Nursing Diagnosis Impaired skin integrity related to pressure over bony prominences and secondary to moisture from bodily secretions as evidenced by superficial ulcerations on patients right ischium, both elbows, both heels, and sacrum. Coping / Family Patient is easily agitated and can be nonconversive and noncompliant at times. Son has fired previous hospice care, so patient is in between hospice. Son has been taking care of patient ineffectively leading to impaired skin integrity and excoriation. Medical History Patient suffers from acute on chronic congestive heart failure, excessive fluid retention resulting in edema, and generalized weeping. Patient can not ambulate without assistance and/or wheelchair. She has a foley catheter in place for urinary elimination and has bowel movements while in bed. Physical Assessment 85 years old (S) + 4 generalized pitting edema (O) Generalized weeping (O) Weakness in all extremities (O) Impaired physical mobility (O) Open wound on right ischium and lower left quadrant of abdomen, closed wound on right heel and left second toe (anterior), intact dressings to elbow and sacral wounds (O) 1 BM in bed at 1300 (O) Nursing Interventions 1. The Troy BSN Student will assess the patients bony prominences for nonblanchable erythema every hours. 2. Troy BSN Student will reposition the patient every 2 hours the prevent skin breakdown. 3. Troy BSN Student will use the Braden Scale to assess the patients risk for pressure ulcer development and reassess at the beginning of each shift. 4. Troy BSN Student will complete a total linen change at least once a shift, if linens are not otherwise soiled, to remove excess moisture from skin. 5. Troy BSN Student will apply Zinc/HC/Clotrimazole compounded cream to patients skin folds to keep all areas protected from irritation and breakdown . Instructions: 1. For medications – list pertinent medications the patient is currently taking, including drug name, action, nursing implications, and evaluation of response to each medication. 2. Pathophysiology – include a brief description of the patho for each medical diagnosis contributing to this patient problem. 3. Medical History – include pertinent facts only 4. Physical assessment – include pertinent facts only 5. Nursing interventions – list interventions specific to this patient problem 6. Coping / Family – include an assessment of the patient’s coping mechanisms, and any family/significant others impact 7. Educational needs – identify pertinent educational needs related to this patient problem 8. Lab Data – include only lab data that is relevant to this patient problem Note: This information is to be very concise. You should ONLY include information related to this problem. If the patient has more than one problem, you will need additional maps, one for each problem.