Académique Documents
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Defining Characteristics
External
Internal
NOC
Outcomes (Nursing Outcomes Classification)
Suggested NOC Outcomes
Client Outcomes
NIC
Interventions (Nursing Interventions Classification)
Suggested NIC Interventions
• Incision Site Care
• Skin Surveillance
• Assess site of skin impairment and determine cause (e.g., acute or chronic wound,
burn, dermatological lesion, pressure ulcer, skin tear). EB: The cause of the
wound must be determined before appropriate interventions can be implemented.
This will provide the basis for additional testing and evaluation to start the
assessment process (Baranoski & Ayello, 2003).
• Monitor site of skin impairment at least once a day for color changes, redness,
swelling, warmth, pain, or other signs of infection. Determine whether the client
is experiencing changes in sensation or pain. Pay special attention to high-risk
areas such as bony prominences, skinfolds, the sacrum, and heels. Systematic
inspection can identify impending problems early (Ayello & Braden, 2002).
• Monitor the client's skin care practices, noting type of soap or other cleansing
agents used, temperature of water, and frequency of skin cleansing.
• Individualize plan according to the client's skin condition, needs, and preferences.
EBN: Avoid harsh cleansing agents, hot water, extreme friction or force, or
cleansing too frequently (Panel for the Prediction and Prevention of Pressure
Ulcers in Adults, 1992; Wound, Ostomy, and Continence Nurses Society WOCN
2003).
• Monitor the client's continence status, and minimize exposure of skin impairment
and other areas of moisture from incontinence, perspiration, or wound drainage.
EBN: Moisture from incontinence contributes to pressure ulcer development by
macerating the skin (WOCN, 2003).
• Do not position the client on site of skin impairment. If consistent with overall
client management goals, turn and position the client at least every 2 hours.
Transfer the client with care to protect against the adverse effects of external
mechanical forces such as pressure, friction, and shear.
• Implement a written treatment plan for topical treatment of the site of skin
impairment. A written plan ensures consistency in care and documentation
(Baranoski & Ayello, 2003; Maklebust & Sieggreen, 2001).
• Select a topical treatment that will maintain a moist wound-healing environment
and that is balanced with the need to absorb exudate. EBN: Choose dressings that
provide a moist environment, keep periwound skin dry, and control exudate and
eliminate dead space (WOCN, 2003).
• Assess the client's nutritional status. Refer for a nutritional consult and/or institute
dietary supplements as necessary. Optimizing nutritional intake, including
calories, fatty acids, protein, and vitamins, is needed to promote wound healing
(Russell, 2001). EB: The benefit of nutritional evaluation and intensive
nutritional support in clients at risk for and with pressure ulcers is not supported
by rigorous clinical trials. Despite this lack of evidence, NPUAP (2006) endorses
the application of reasonable nutritional assessment and treatment for clients at
risk for and with pressure ulcers.
• Identify the client's phase of wound healing (inflammation, proliferation,
maturation) and stage of injury. Accurate understanding of tissue status combined
with knowledge of underlying diagnoses and product validity provide a basis for
determining appropriate treatment objectives. No single wound dressing is
appropriate for all phases of wound healing (Ovington, 1999).
Home Care
• Instruct and assist the client and caregivers in how to change dressings and
maintain a clean environment. Provide written instructions and observe them
completing the dressing change.
• Educate client and caregivers on proper nutrition, signs and symptoms of
infection, and when to call the agency and/or physician with concerns.
Client/Family Teaching
• Teach skin and wound assessment and ways to monitor for signs and symptoms of
infection, complications, and healing. Early assessment and intervention help
prevent serious problems from developing.
REFERENCES
Constipation
Defining Characteristics
Functional
Pharmacological
Mechanical
Physiological
NOC
Outcomes (Nursing Outcomes Classification)
Suggested NOC Outcomes
• Bowel Elimination
Client Outcomes
• Constipation/Impaction Management