Assessment Nursing Scientific Planning Interventions Rationale Evaluation

Diagnosis Explanation
S: “lagi na lang Risk for Impaired Immobility, Patient’s skin  establish rapport  to facilitate NPI Patient’s skin
akong nkahiga” as Skin Integrity r/t which leads to remains intact,  place the pt in a  to prevent remained intact,
verbalized by the comfortable position backaches or
patient.
prolonged bed pressure, shear, as evidenced by as evidenced by
muscle aches.
rest and altered and friction, is no redness over  take and record  to note any
no redness over
O: circulation 2o the factor most bony vital signs significant changes bony
 c standby O2 @ present likely to put an prominences that may be prominences
bedside condition individual at risk and absence of brought about by and absence of
 c good capillary for altered skin skin breakdown.  Determine age. the disease skin breakdown.
refill in 2-3 secs.  Elderly
 on low
integrity.
patients’ skin is
cholesterol, low Advanced age; normally less
sugar diet the normal loss elastic and has
 c good appetite, of elasticity; less moisture,
consumed all foods inadequate  Assess general making for higher
served condition of skin. risk of skin
nutrition;
 c body malaise impairment.
environmental  Healthy skin
 c bradycardia (40
CPM)] moisture, varies from
 on CBR especially from individual to
 c limited ROM incontinence; individual, but
 ambulatory c and vascular should have good
assistance turgor, feel warm
insufficiency and dry to the
 Specifically assess
potentiate the skin over bony touch, be free of
effects of prominences impairment, and
pressure and have quick capillary
hasten the refill (<6 seconds).
 Areas where
development of skin is stretched
skin breakdown. tautly over bony
Groups of prominences are
persons with the at higher risk for
highest risk for breakdown
because the
altered skin
integrity are the  Assess patient’s possibility of
spinal cord ability to move. ischemia to skin
is high as a result
injured, those of compression of
 Reassess skin
who are often and skin capillaries
confined to bed whenever the between a hard
or wheelchair for patient’s surface and the
prolonged condition or bone.
treatment plan  Immobility is
periods of time,
results in an the greatest risk
those with increased number factor in skin
edema, and of risk factors. breakdown.
those who have  encourage  The incidence
altered change of position and onset of skin
sensation that in a regular basis breakdown is
 provide directly related to
triggers the the number of
adequate
normal clothing/covers; risk factors
protective protect from present.
weight shifting. drafts
Pressure relief  emphasize  to prevent
importance of pressure to
and pressure certain parts of
adequate
reduction nutritional/ fluid the body
devices for the intake  to prevent
prevention of  recommend vasoconstriction
skin breakdown keeping nails
include a wide short  to maintain
general good
range of health and skin
surfaces,  recommend turgor
specialty beds elevation of lower
and mattresses, extremities when  to reduce risk
and other sitting of dermal injury
 encourage when severe
devices. itching is present
ambulation as
tolerated  to enhance
venous return
and reduce
edema formation
 to enhance
circulation