NURSING CARE PLAN
Assessment NursingDiagnosisScientificExplanationPlanning Interventions Rationale Evaluation
S: “lagi na langakong nakahiga”as verbalized bythe patient.O:
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
place the pt in acomfortable position
take and recordvital signs
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