Problem 1 Impaired skin integrity related to pressure ulcer stage III evidence by disruption of epidermal and dermal tissues in coccyx area.
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
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.
Imbalanced nutrition less than body requirements related to poor nutrition intake as manifested by patient losing weight.
Patient will gain one to two pounds in two weeks over the next week
Monitor intake, calorie count