Mrs. MB is 104 year female admitted to the facility on 01/15/2008. She looks thin and malnourished. Patient’s weight 113.5 lbs. patient has advance stage of Alzheimer’s. She also has hypertension, cataract, anemia, and B12 deficiency. Contracture is noted in the right arm. Patient is non-ambulatory as lead to her being bed ridden. On assessment I noted that the patient has a stage III pressure ulcer on her coccyx area.

Problem 1 Impaired skin integrity related to pressure ulcer stage III evidence by disruption of epidermal and dermal tissues in coccyx area.

Goals

Patient wounds will be kept clean and will not develop an infection.
Patient will have evidence of wound healing within a week.
Decreased wound size

Interventions

Reposition the patient every two hours.
Patient wound will be cleaned with normal saline put dry and apply Sulfadine cream as ordered by the PCP and proper hand hygiene will be performed before and after cleaning.
Inspect skin surfaces and pressure points routinely
Change patient’s briefs frequently and cleanse perineal after each incontinence episode and apply skin protectant ointments.
Keep bed linens clean, dry, and wrinkle free.

Evaluation:

Problem2
Imbalanced nutrition less than body requirements related to poor nutrition intake as manifested by patient losing weight.
Goal:
Patient will gain one to two pounds in two weeks over the next week
Interventions
Nutrition consult
Monitor intake, calorie count
Weekly