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    Impaired Skin Integrity

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    Eli Ayase
    A 5-month-old patient presented with a 1x1 cm ulcerated wound on the left thigh and signs of cellulitis including redness, swelling, and tenderness of the skin. The nursing diagnosis was impaired skin integrity related to bacterial infection secondary to cellulitis. The plan was to keep the area clean and dry, apply appropriate dressings, administer intravenous antibiotics including clindamycin and gentamicin, and instruct the mother on prevention measures and wound care. The goals were to promote healing, prevent infection, and assess the status of the wound and involvement of the infection over 8 hours.

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    Impaired Skin Integrity

    Uploaded by

    Eli Ayase
    325 views2 pages
    A 5-month-old patient presented with a 1x1 cm ulcerated wound on the left thigh and signs of cellulitis including redness, swelling, and tenderness of the skin. The nursing diagnosis was impaired skin integrity related to bacterial infection secondary to cellulitis. The plan was to keep the area clean and dry, apply appropriate dressings, administer intravenous antibiotics including clindamycin and gentamicin, and instruct the mother on prevention measures and wound care. The goals were to promote healing, prevent infection, and assess the status of the wound and involvement of the infection over 8 hours.

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    A 5-month-old patient presented with a 1x1 cm ulcerated wound on the left thigh and signs of cellulitis including redness, swelling, and tenderness of the skin. The nursing diagnosis was impaired skin integrity related to bacterial infection secondary to cellulitis. The plan was to keep the area clean and dry, apply appropriate dressings, administer intravenous antibiotics including clindamycin and gentamicin, and instruct the mother on prevention measures and wound care. The goals were to promote healing, prevent infection, and assess the status of the wound and involvement of the infection over 8 hours.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    325 views2 pages

    Impaired Skin Integrity

    Uploaded by

    Eli Ayase
    A 5-month-old patient presented with a 1x1 cm ulcerated wound on the left thigh and signs of cellulitis including redness, swelling, and tenderness of the skin. The nursing diagnosis was impaired skin integrity related to bacterial infection secondary to cellulitis. The plan was to keep the area clean and dry, apply appropriate dressings, administer intravenous antibiotics including clindamycin and gentamicin, and instruct the mother on prevention measures and wound care. The goals were to promote healing, prevent infection, and assess the status of the wound and involvement of the infection over 8 hours.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    Patient’s Name: Ms.

    XX Chief Complaints: Wound infection


    Room/ Bed #: MISC 1 Diagnosis/ Impression: Ulcerated wound 1x1 cm on left thigh
    Age: 5 months old Attending Physician: Dr. YY
    General Objective: To promote safety through prevention of accidents, injury or other trauma and through the prevention of the spread of infection.
    CUES NURSING RATIONALE SPECIFIC INTERVENTION RATIONALE EVALUATION
    DIAGNOSIS OBJECTIVES
    Subjective: Impaired skin Break in the skin Within 8 hours of Independent: After 8 hours of
    “napilas ni siya integrity related (wound, laceration, rendering nursing care 1. Note changes in skin 1. To assess extent of rendering nursing care to
    tapos wala na to bacterial scrape, cuts) at PEDIA - CLMMRH, color, texture and turgor. involvement or injury the patient, the patient’s
    talupangdan” infection I will be able to mother participated in
    secondary to promote participation of 2. Keep the area 2. To assist body’s preventive measures and
    Objectives: cellulitis caregiver in prevention clean/dry, prevent natural process of repair. treatment programs for her
    Organisms in the skin measures and treatment infection, and stimulate child as evidenced by:
     Face grimace gain entrance to the regimen for the infected circulation to  The mother was able
    noted dermis (S. areus/ Group area of the patient. surrounding areas. to verbalize
    A streptococcus) understanding of
     Redness and 3. Apply appropriate 3. Wound dressings health teachings
    lesion on left dressing protect the wound and  Lesions were kept
    thigh noted the surrounding tissues. clean and dry

     Tight, glossy Skin on the left thigh is 4. Perform nail care to 4. Long and rough nails
    appearance of swollen, red and tender, the patient increase risk of skin
    the skin on the tight, and glossy damage
    left thigh noted
    5. Instruct folks to let 5. To prevent the patient
    patient wear mittens from touching or
    Impaired skin integrity scratching the infected
    Other pertinent wound
    data:
     Medications:
     clindamycin Dependent:
    40mg IVTT 1. If indicated, administer
    q6h medications such as
     gentamicin antibiotic in accordance
    20mg IVTT to the 12 rights of drug
    OD administration.
     fluconazole  Medication:
    50mg/pptab References:  clindamycin  To stop the growth of
    OD Belleza, M. (2017, 40mg IVTT q6h bacteria.
    September 26).  gentamicin 20mg  To help fight bacteria
     HGB (g/dl): 93 Cellulitis. Retrieved and to treat severe or
    IVTT OD
    (0.5) from nurseslabs: serious bacterial
     HCT (%):0.29 https://nurseslabs.co infection.
    (32) m/cellulitis/?  fluconazole  to prevent and treat a
     RBC (x 106 /µL): fbclid=IwAR12gIVs 50mg/pptab OD variety of fungal
    3.27 YEOoGbaIrCH_3E8 and yeast infections
     WBC (x 10ᵌ /µL): 7prxG8LnuDj_bT_
    5.7 AqAHXpNuvKbIE-
     Lymphocytes TTmzbTM
    (%): 20
     Monocytes
    (%):15

    References:
    Belleza, M. (2017, September 26). Cellulitis. Retrieved from nurseslabs: https://nurseslabs.com/cellulitis/?
    fbclid=IwAR12gIVsYEOoGbaIrCH_3E87prxG8LnuDj_bT_AqAHXpNuvKbIE-TTmzbTM
    Nanda Health. (2013, October 27). Impaired Skin Integrity related to Cellulitis Care Plan. Retrieved from Nanda Health: https://nanda-health.blogspot.com/2013/10/impaired-
    skin-integrity-related-to.html

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