- Impaired Physical Mobility related to prescribed bed rest or activity restriction and decreased muscle strength as evidenced by Limited range of motion and Inability to turn self or reposition
- Impaired Skin Integrity related to Poor nutritional status and moisture/Incontinence as evidenced by verbalization of pain or numbness to the affected area and alterations in skin color (blanching, bruising, erythema)
- Ineffective Peripheral Tissue Perfusion related to Circulatory compromise and Insufficient knowledge of comorbidities or risk factors as evidenced by Skin discoloration and delayed peripheral wound healing
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: -Expression of pain and discomfort with movement -Refusal to move Objective Data: -Limited range of motion -Uncoordinated movements -Poor balance -Inability to turn in bed, transfer, or ambulate -Postural instability | Impaired Physical Mobility related to prescribed bed rest or activity restriction and decreased muscle strength as evidenced by Limited range of motion and Inability to turn self or reposition | Patient will participate in their activities of daily life (ADLs) and prescribed therapies. Patient will display improvement in physical mobility by transferring from bed to wheelchair independently (if this is a realistic goal). Patient will remain free of contractures and decubitus ulcers from impaired mobility. Patient will demonstrate exercises to improve physical mobility. | 1. Implement devices for independence with repositioning. Patients with some ability to move or reposition should be provided with trapeze bars and side rails to pull themselves up or turn over. 2. Use wedges, pillows, and mattresses. Pressure ulcers often occur on boney prominences such as the sacrum, heels, and hips. Keep these areas protected with foam wedges, heel protectors, pillows, and air mattresses. 3. Treat pain. Patients may be reluctant to move or reposition due to pain and discomfort. Medicate before turning and repositioning. For chronic pain, administer pain medications routinely to allow for ease of movement. 4. Instruct on areas to inspect for breakdown. Educate patients and family members on additional areas subject to shearing and friction such as the back of the head, elbows, ears, and back. 5. Transfer to chairs and assist with ambulation. Patients should be assisted out of bed to the chair and to ambulate if able to do so safely. This allows circulation to the tissues and relieves pressure. 6. Implement a turning schedule. Evidence-based practice recommends turning bed-bound patients every 2 hours to prevent pressure ulcer development. Patients in wheelchairs or sitting up should be reminded to reposition themselves every 15 minutes to redistribute weight. | Patient participated in their activities of daily life (ADLs) and prescribed therapies. Patient displayed improvement in physical mobility by transferring from bed to wheelchair independently (if this is a realistic goal). Patient remained free of contractures and decubitus ulcers from impaired mobility. Patient demonstrated exercises to improve physical mobility. |
| Subjective Data: -Pain -Itching -Numbness to affected and surrounding skin Objective Data: -Changes to skin color (erythema, bruising, blanching) -Warmth to skin -Swelling to tissues -Observed open areas or breakdown, excoriation | Impaired Skin Integrity related to Poor nutritional status and moisture/Incontinence as evidenced b verbalization of pain or numbness to the affected area and alterations in skin color (blanching, bruising, erythema) | Patient will maintain intact skin integrity. Patient will experience timely healing of wounds without complications. Patient will demonstrate effective wound care. Patient will verbalize proper prevention of pressure injuries. | 1. Collaborate with wound care experts. Wound care nurses should be involved at the beginning of any skin breakdown to prevent further deterioration and monitor closely. Severe pressure ulcers or those with delayed healing may require outpatient follow-up with a wound specialist. 2. Encourage nutrition and hydration. Poor nutrition and hydration interfere with immune function as well as collagen production and tensile strength of the skin. Protein intake, vitamins A, C & E, and zinc support wound healing. Enteral nutrition and IV fluids may be necessary for adequate nutrition. 3. Keep skin clean and dry. Patients who are incontinent or who cannot verbalize their need to be cleaned require frequent perineal care and linen changes. Sweat, urine, and feces create an environment that is irritating to the skin. 4. Perform necessary wound care. Wound care orders will depend on the type, size, and location of the pressure ulcer. Proper cleansing and application of ointments, sprays, foams, and dressings will aid in healing and the prevention of further breakdown. | Patient maintained intact skin integrity. Patient experienced timely healing of wounds without complications. Patient demonstrated effective wound care. Patient verbalized proper prevention of pressure injuries. |
Subjective Data: Chest Pain Dyspnea Sense of impending doom Objective Data: -Arrhythmia’s -Capillary refill >3 seconds -Altered respiratory rate -Use of accessory muscles to breathe -Abnormal arterial blood gases -Unstable blood pressure -Tachycardia or bradycardia -Cyanosis | Ineffective Peripheral Tissue Perfusion related to Circulatory compromise and Insufficient knowledge of comorbidities or risk factors as evidenced by Skin discoloration and delayed peripheral wound healing | Patient will maintain adequate peripheral perfusion as evidenced by strong pedal pulses, warm skin temperature, and intact skin without edema. Patient will maintain cardiopulmonary perfusion as evidenced by normal sinus heart rhythm, heart rate within normal limits, no complaints of shortness of breath and normal Sa02. Patient will demonstrate appropriate lifestyle modifications to support adequate tissue perfusion. Patient will have an improvement in cerebral perfusion as evidenced by intact orientation to person, place, and time. | 1. Perform routine skin assessments. Patients with a known history of vascular disorders, diabetes mellitus, poor mobility, or other conditions that affect peripheral perfusion should receive frequent skin assessments to monitor for changes in skin color, temperature, or sensation that indicate impaired perfusion and increase the risk for pressure ulcers. 2. Encourage movement or consult with physical therapy. Patients should be assisted with movement within their capabilities to promote circulation. Expert advice from a physical therapist can help patients with pressure ulcers plan appropriate exercise regimens or mobility techniques to promote tissue perfusion. 3. Take caution when applying heat or cold. Patients with impaired tissue perfusion may lack the sensory perception to recognize heat or cold and should take caution if applying heating pads or ice packs. Heat or cold should never be applied to pressure ulcers as these further damages compromised tissue. 4. Educate the patient about their risk factors. Patients may lack knowledge surrounding their medical history that predisposes them to pressure ulcers, such as a stroke or other neurological condition that disrupts their sensory perception or causes unilateral neglect. The nurse can also educate on modifiable risk factors that disrupt perfusion, like smoking or obesity. | Patient maintained adequate peripheral perfusion as evidenced by strong pedal pulses, warm skin temperature, and intact skin without edema. Patient maintained cardiopulmonary perfusion as evidenced by normal sinus heart rhythm, heart rate within normal limits, no complaints of shortness of breath and normal Sa02. Patient demonstrated appropriate lifestyle modifications to support adequate tissue perfusion. Patient shown improvement in cerebral perfusion as evidenced by intact orientation to person, place, and time. |