Care Plan for Bruise/Skin Tear Management

Category / Primary Body System

• Integumentary System

Problem

• Patient is at risk of complications due to the presence of bruises and/or skin tears.

Goal

• Bruises and/or skin tears will resolve within 30 days.

Plan/Approach

1. Careful Handling and Assistance

   • Use caution when assisting with ADLs (e.g., washing, dressing) to prevent further injury.
   • Remove footrests from the wheelchair prior to transfers to avoid accidental skin tears.
   • Use pillows or padding when the patient is in bed to protect vulnerable skin areas.

2. Hydration and Nutrition

   • Provide adequate fluids if not contraindicated to support skin health and healing.

3. Pain Management

   • Monitor for any signs or symptoms of pain and document findings.
   • Administer pain medication as ordered and monitor effectiveness.
   • Notify MD/NP if pain is not controlled despite medication.

4. Wound Care

   • Treat affected areas as needed following wound care protocols.
   • Monitor for signs of infection (e.g., redness, warmth, swelling, discharge) and notify the MD/NP if any are observed.

5. Communication and Documentation

   • Document all interventions and patient responses in the medical record.
   • Communicate with the healthcare team regarding the patient's progress and any concerns.

6. Patient and Family Education

   • Educate the patient and family on proper skin care and techniques to prevent further injury.
   • Provide instructions on recognizing signs of complications such as infection and when to seek medical attention.

Rationale

1. Careful Handling and Assistance

   • Gentle handling during ADLs reduces the risk of skin tears and bruises, promoting healing and preventing further injury.
   • Removing wheelchair footrests prevents accidental injuries during transfers.
   • Using pillows and padding helps protect the skin from pressure and friction.

2. Hydration and Nutrition

   • Adequate hydration is essential for maintaining skin integrity and promoting healing.

3. Pain Management

   • Monitoring and managing pain ensures patient comfort and promotes participation in daily activities and healing.

4. Wound Care

   • Proper wound care prevents infection and promotes faster healing of bruises and skin tears.

5. Communication and Documentation

   • Thorough documentation and communication with the healthcare team ensure continuity of care and timely interventions when needed.

6. Patient and Family Education

   • Educating the patient and family empowers them to take an active role in care and prevention, improving outcomes.

Actions

1. Careful Handling and Assistance

   • Assist the patient gently with ADLs, being mindful of areas prone to bruising and tearing.
   • Ensure footrests are removed from the wheelchair before any transfers.
   • Place pillows or padding in strategic areas when the patient is in bed to prevent pressure injuries.

2. Hydration and Nutrition

   • Encourage the patient to drink fluids regularly, unless contraindicated by medical conditions.

3. Pain Management

   • Assess the patient's pain level regularly, using a standardized pain scale.
   • Administer prescribed pain medications and evaluate their effectiveness.
   • Report uncontrolled pain to the MD/NP for further management.

4. Wound Care

   • Clean and dress wounds according to protocol, ensuring the use of aseptic techniques.
   • Monitor for signs of infection and report any abnormalities to the MD/NP.

5. Communication and Documentation

   • Record all care activities, patient responses, and any changes in condition in the patient's medical record.
   • Update the healthcare team during rounds or through electronic health records about the patient's progress.

6. Patient and Family Education

   • Teach the patient and family about gentle skin care, including proper bathing and moisturizing techniques.
   • Provide educational materials on signs of complications and when to contact healthcare providers.