THE WAYNE COUNTY COMMUNITY COLLEGE DISTRICT NURSING PROGRAM

| O: 61 year old post op pt has gone cholecystectomy. Pt is nonverbal and immobile. Pt has stage 2 breakdown on scrotum and stage 1, 2×2 redness around anus Nursing Diagnosis:Impaired skin integrity related to physical immobilization AEB Stage 2 skin breakdown on scrotum, and stage 5 skin impairment on anus Theoretical Knowledge:Targeting variables can focus assessment on particular factors and help guide the plan of care and prevention | 1. 1 pt will not have breakdown of skin around anus throughout shift 2. 1 Report any alteration in redness or pain at site of skin impairment q4 hrs3. 1 Regain skin integrity of skin surface within a month

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