Determine that skin impairment involves skin damage only (e.g., partial-thickness wound, stage I or stage II pressure ulcer). Prior assessment of wound etiology is critical for proper identification of nursing interventions (van Rijswijk, 2001). Assess site of skin impairment and determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, skin tear) (Krasner, Sibbald, 1999). Both teaching and nursing plans imply care only at home since the patient experiences painful sensations in the open air.Mechanical factors (e.g., friction, shearing forces, pressure, restraint) altered nutritional state (e.g., obesity, emaciation) alterations in skin turgor (change in elasticity) NOC Outcomes (Nursing Outcomes Classification) Tissue Integrity: Skin and Mucous Membranes Reports any altered sensation or pain at site of skin impairment Demonstrates understanding of plan to heal skin and prevent reinjury Describes measures to protect and heal the skin and to care for any skin lesion NIC Interventions (Nursing Interventions Classification) 1. Alteration in comfort and impaired skin integrity can be treated with the help of timely procedures and appropriate control. Thus, both the described diagnoses can be applied to the patient, and for faster recovering, it is significant for Mary to follow nurses’ recommendations and advice. In addition, the patient can be offered electronic resources to study relevant and useful information. Memos and videos can be useful for visualizing ways to protect against external factors. Also, as a care plan, it is required to monitor drug intake and to timely provide therapeutic procedures.įor teaching purposes, it is possible to use information about the conditions of being in the locality with other climatic features. According to Iori, Foracchia, and Gradellini (2015), as a nursing intervention for a breach of the integrity of the skin, it can be ensured that there are no changes in temperature, and the patient stays at the same environment. The damage caused by climate change can cause rash and itching. The woman spent much in the open air, and the air in the mountains, as it is known, is different from the urban one. Impaired skin integrity is one of the possible diagnoses that is quite likely in the case of Mary. Nevertheless, it is essential to control that the patient does not experience physical exertion, timely takes medications, and is aware of the features of the treatment plan. As Gordon (2014) remarks, no special measures and efforts are required. In order to care for the patient, it is required to provide her with peace. Also, in order to avoid worrying about possible health consequences, it is required to inform Mary that her illness will not have any significant consequences for her body if she follows the prescriptions of the doctor and temporarily refrains from serious strains. The patient should be told about all possible manifestations of her problem and be provided with full information about the method of treatment that will be prescribed by her attending physician. A possible reason for this diagnosis is the recent Mary’s hiking and camping in the Appalachian Mountains where her living conditions did not match the usual ones, and the rash and accompanying symptoms began to occur. According to Gordon (2014), this problem is often expressed in the form of the rash that the patient has on her face. One of the possible diagnoses can be the alteration in comfort, which, in its turn, leads to joint pain and other symptoms described by the patient – weakness, increased fatigue, weight loss. Learn more Alteration in Comfort: Teaching and Nursing Care Plans
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