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NCP - Impaired Skin Integrity

The patient was at risk for impaired skin integrity due to right-sided heart enlargement causing edema. The nurse's goals were to maintain the patient's skin integrity over 8 hours by keeping skin turgor good, preventing edema, and maintaining normal vital signs. Interventions included strict skin hygiene, regular position changes, adequate clothing, pillow use, reddened area observation, fluid intake, exercise, lotion use, and leg elevation when sitting. After 8 hours the goals were partially met, with good skin turgor and no edema, though vital signs were slightly abnormal.

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4K views1 page

NCP - Impaired Skin Integrity

The patient was at risk for impaired skin integrity due to right-sided heart enlargement causing edema. The nurse's goals were to maintain the patient's skin integrity over 8 hours by keeping skin turgor good, preventing edema, and maintaining normal vital signs. Interventions included strict skin hygiene, regular position changes, adequate clothing, pillow use, reddened area observation, fluid intake, exercise, lotion use, and leg elevation when sitting. After 8 hours the goals were partially met, with good skin turgor and no edema, though vital signs were slightly abnormal.

Uploaded by

janelee2824
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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Date/ Time A U G U S T 19, 2010 3PM

RISK FOR IMPAIRED SKIN Cues INTEGRITY Nursing Need


Subjective: ingon si doc na mau lang ng hupong ko kay nagdaku daw akong heart tong jan as verbalized by the patient Objective: Good skin turgor No edema noted Palor noted CRT of greater than 2 seconds N U T R I T I O N A L M E T A B O L O C P A T T E R N Diagnosis Risk for impaired skin integrity related to altered circulation secondary to right sided hypertrophy a manifestation of right ventricular hypertrophy is edema. Groups of persons with the highest risk for altered skin integrity are those with edema.

Objectives After 8 hours span of care, my patient will be able to maintain skin integrity, as manifested by: 1. Good skin turgor 2. No edema noted 3. Maintai n vital signs within the normal range (BP:110/7 0-130/90; CR: 7090; RR: 16-20; T: 25.8-37.5)

Nursing Intervention 1. Maintain strict skin hygiene to maintain skin integrity at optimal level 2. Change position in bed on a regular schedule prevent pressure sores 3. Provide adequate clothing prevent vasoconstriction 4. Provide protection by use of pillow increase circulation and eliminate excessive tissue pressure 5. Observe for reddened areas reduces likelihood of progression to skin breakdown 6. Emphasize importance of adequate fluid intake maintain good health and skin turgor 7. Recommend continuation of regular exercise program enhance circulation 8. Suggest use of lotions decrease irritable itching 9. Recommend elevation of lower extremities when sitting enhance venous return and reduce edema formation

Evaluation August 19, 2010 11PM GOAL PARTIALLY MET! After 8 hours span of care, my patient was able to maintain skin integrity as manifested by: 1. Good skin turgor 2. No edema on extremities 3. BP: 120/60; CR: 65; T: 35.6; RR: 22

90

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