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ncp 3

ncp 3

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Published by hsiria

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Published by: hsiria on Jun 03, 2009
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01/01/2014

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NURSING CARE PLAN
Assessment NursingDiagnosisScientificExplanationPlanning Interventions Rationale Evaluation
S: “lagi na langakong nakahiga”as verbalized bythe patient.O:
Conscious andcoherent
drowsy onappearnace
c sunkeneyeballs
c bodyweakness
restless
c poorappetite;consumed ¼ of the food served
c limited ROM
ambulatory cassistanceRisk for ImpairedSkin Integrity r/tprolonged bedrest
Immobility, whichleads to pressure,shear, and friction, isthe factor most likelyto put an individualat risk for alteredskin integrity.Advanced age; thenormal loss of elasticity; inadequatenutrition;environmentalmoisture, especiallyfrom incontinence;and vascular insufficiency potentiate the effectsof pressure andhasten thedevelopment of skin breakdown. Groupsof persons with thehighest risk for altered skin integrityare the spinal cordinjured, those whoare confined to bed
Patient’s skinremains intact,as evidenced byno redness overbonyprominences andabsence of skinbreakdown
establish rapport
place the pt in acomfortable position
take and recordvital signs
Determine age.
Assess generalcondition of skin.
Specifically assessskin over bonyprominences
to facilitate NPI
to preventbackaches ormuscle aches.
to note anysignificant changesthat may be broughtabout by thedisease
Elderly patients’skin is normally lesselastic and has lessmoisture, makingfor higher risk of skin impairment.
Healthy skinvaries fromindividual toindividual, butshould have goodturgor, feel warmand dry to thetouch, be free of impairment, andhave quick capillaryrefill (<6 seconds).
Areas where skinis stretched tautlyover bonyprominences are athigher risk forbreakdown because
Patient’s skinremained intact,as evidenced byno redness overbonyprominences andabsence of skinbreakdown
 
or wheelchair for  prolonged periods of time, those withedema, and thosewho have alteredsensation thattriggers the normal protective weightshifting. Pressurerelief and pressurereduction devices for the prevention of skin breakdowninclude a wide rangeof surfaces, specialty beds and mattresses,and other devices.Preventive measuresare usually notreimbursable, eventhough costs relatedto treatment once breakdown occursare greater.
Assess patient’sability to move.
Reassess skinoften and wheneverthe patient’scondition ortreatment planresults in anincreased number of risk factors.
encourage changeof position in aregular basis
provide adequateclothing/covers;protect from drafts
emphasizeimportance of adequate nutritional/fluid intake
recommendkeeping nails short
recommendelevation of lowerextremities whensitting
encourageambulation astoleratedthe possibility of ischemia to skin ishigh as a result of compression of skincapillaries betweena hard surface andthe bone.
Immobility is thegreatest risk factorin skin breakdown
.
The incidence andonset of skinbreakdown isdirectly related tothe number of riskfactors present.
to preventpressure to certainparts of the body
to preventvasoconstriction
to maintaingeneral good healthand skin turgor
to reduce risk of dermal injury whensevere itching ispresent
to enhancevenous return andreduce edemaformation
to enhance

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