Updated Care Plan for Bruise/Skin Tear

Category / Primary Body System:

Integumentary System / Skin Integrity

Problem:

The patient is at risk for complications due to the presence of a bruise and/or skin tear.

Goal:

The bruise and/or skin tear will resolve within 30 days.

Plan/Approach:

1. ADL Assistance:

   • Step: Use caution when assisting with activities of daily living (ADLs) such as washing and dressing.
   • Rationale: Gentle handling minimizes the risk of further injury to fragile skin.
   • Actions: Use soft cloths and gentle motions, avoid harsh rubbing, and ensure the patient is positioned comfortably during care activities.

2. Wheelchair Safety:

   • Step: Remove footrests from the wheelchair prior to transfers.
   • Rationale: Removing obstacles reduces the risk of additional injury during transfers.
   • Actions: Ensure the wheelchair is properly positioned and footrests are removed before helping the patient transfer.

3. Padding and Positioning:

   • Step: Use pillows or padding when the patient is in bed if appropriate.
   • Rationale: Proper padding prevents pressure and friction that can exacerbate skin tears and bruising.
   • Actions: Position pillows to cushion bony prominences and support the affected area, ensuring the patient is comfortable.

4. Hydration:

   • Step: Provide adequate fluids if not contraindicated.
   • Rationale: Adequate hydration supports skin health and healing.
   • Actions: Monitor the patient’s fluid intake, encourage regular drinking, and provide hydration through preferred beverages.

5. Pain Monitoring:

   • Step: Monitor for any signs and symptoms of pain.
   • Rationale: Early detection of pain allows for timely intervention and pain management.
   • Actions: Regularly assess the patient’s pain using appropriate pain scales, observe for non-verbal signs of pain, and document findings.

6. Pain Management:

   • Step: Medicate for pain as ordered.
   • Rationale: Effective pain management promotes comfort and aids in the healing process.
   • Actions: Administer prescribed pain medications on schedule, and evaluate their effectiveness. Adjust the pain management plan in consultation with the healthcare provider if needed.

7. Pain Reporting:

   • Step: Notify the MD/NP if pain is not controlled.
   • Rationale: Prompt reporting of uncontrolled pain ensures timely adjustment of the pain management plan.
   • Actions: Document instances of uncontrolled pain and communicate them to the MD/NP for further evaluation and intervention.

8. Treatment of Affected Area:

   • Step: Provide treatment to the affected area as needed.
   • Rationale: Proper treatment of the bruise or skin tear promotes healing and prevents infection.
   • Actions: Clean the affected area with appropriate solutions, apply prescribed dressings, and follow wound care protocols. Monitor for signs of infection and report any concerns.