Care Plan for Bruise/Skin Tear Management
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
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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.
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Hydration and Nutrition
- Provide adequate fluids if not contraindicated to support skin health and healing.
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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.
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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.
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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.
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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
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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.
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Hydration and Nutrition
- Adequate hydration is essential for maintaining skin integrity and promoting healing.
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Pain Management
- Monitoring and managing pain ensures patient comfort and promotes participation in daily activities and healing.
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Wound Care
- Proper wound care prevents infection and promotes faster healing of bruises and skin tears.
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Communication and Documentation
- Thorough documentation and communication with the healthcare team ensure continuity of care and timely interventions when needed.
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Patient and Family Education
- Educating the patient and family empowers them to take an active role in care and prevention, improving outcomes.
Actions
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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.
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Hydration and Nutrition
- Encourage the patient to drink fluids regularly, unless contraindicated by medical conditions.
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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.
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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.
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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.
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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.
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