Care Plan for Managing Actual Skin Breakdown

Care Plan for Managing Actual Skin Breakdown

Category / Primary Body System

• Integumentary System

Problem

• Patient has actual skin breakdown.

Goal

• Patient’s skin breakdown will heal without complications in 90 days.

Plan/Approach

1. Treatment and Medication

   • Perform treatment as ordered by the healthcare provider to ensure proper care of the skin breakdown.
   • Administer medications as ordered to manage pain, prevent infection, and promote healing.

2. Nutrition

   • Provide diet as ordered, ensuring it includes nutrients essential for skin healing such as protein, vitamins A and C, and zinc.
   • Encourage fluid intake if not contraindicated to maintain skin hydration and overall health.

3. Monitoring and Evaluation

   • Evaluate the progress of treatment weekly, documenting the condition of the skin and any changes.
   • Monitor the skin breakdown for increased drainage and odor, and notify the MD/RNP as needed to address potential infection or complications.

4. Pressure Relief

   • Use a pressure-relieving mattress at all times to reduce pressure on the affected area and prevent further breakdown.

Rationale

1. Treatment and Medication

   • Proper treatment and medication management are crucial for promoting healing, preventing infection, and managing pain associated with skin breakdown.

2. Nutrition

   • Adequate nutrition and hydration are essential for tissue repair and overall health, aiding the healing process of skin breakdown.

3. Monitoring and Evaluation

   • Regular monitoring and evaluation allow for timely identification and management of complications, ensuring the treatment plan is effective.

4. Pressure Relief

   • Reducing pressure on the affected area prevents further damage and supports the healing process.

Actions

1. Treatment and Medication

   • Perform wound care treatments as ordered, following sterile technique and documenting the procedure.
   • Administer prescribed medications, including pain management and antibiotics if necessary, monitoring for effectiveness and side effects.

2. Nutrition

   • Provide a balanced diet rich in protein, vitamins, and minerals to support healing.
   • Encourage fluid intake, monitoring for signs of dehydration and contraindications.

3. Monitoring and Evaluation

   • Assess the wound weekly, documenting size, depth, drainage, and any signs of infection.
   • Notify the MD/RNP of any changes or concerns, particularly increased drainage or odor.

4. Pressure Relief

   • Ensure the patient uses a pressure-relieving mattress, positioning them to reduce pressure on the affected area.
   • Reposition the patient every two hours to further alleviate pressure and promote circulation.