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  • Assessment Diagnosis Planning Intervention Rationale Evaluation

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    mykmicua
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    The patient was experiencing numbness and pain in their hands and feet. The nurse assessed for skin integrity issues related to alterations in skin temperature, turgor, and edema. Over the next few hours of nursing intervention, the patient maintained intact skin. The nurse inspected the skin for changes in color, temperature, turgor, and vascularity; noted any redness; and monitored fluid intake and hydration of the skin and mucous membranes. After the nursing intervention, the patient continued to maintain intact skin. The nurse inspected dependent areas for edema and elevated the patient's legs as indicated to promote venous return, limit venous stasis and edema formation, prevent direct dermal irritation, and promote evaporation of moisture on the skin

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    ncp

    Original Title

    Ncp - Edema

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    The patient was experiencing numbness and pain in their hands and feet. The nurse assessed for skin integrity issues related to alterations in skin temperature, turgor, and edema. Over the next few hours of nursing intervention, the patient maintained intact skin. The nurse inspected the skin for changes in color, temperature, turgor, and vascularity; noted any redness; and monitored fluid intake and hydration of the skin and mucous membranes. After the nursing intervention, the patient continued to maintain intact skin. The nurse inspected dependent areas for edema and elevated the patient's legs as indicated to promote venous return, limit venous stasis and edema formation, prevent direct dermal irritation, and promote evaporation of moisture on the skin

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    10 views1 page

    Assessment Diagnosis Planning Intervention Rationale Evaluation

    Uploaded by

    mykmicua
    The patient was experiencing numbness and pain in their hands and feet. The nurse assessed for skin integrity issues related to alterations in skin temperature, turgor, and edema. Over the next few hours of nursing intervention, the patient maintained intact skin. The nurse inspected the skin for changes in color, temperature, turgor, and vascularity; noted any redness; and monitored fluid intake and hydration of the skin and mucous membranes. After the nursing intervention, the patient continued to maintain intact skin. The nurse inspected dependent areas for edema and elevated the patient's legs as indicated to promote venous return, limit venous stasis and edema formation, prevent direct dermal irritation, and promote evaporation of moisture on the skin

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Assessment

    Diagnosis

    Planning

    Intervention

    Rationale

    Evaluation

    SUBJECTIVE: Namamanas ang kamay at paa ko as verbalized by the patient b!e"tive:

    #isk $or skin integrity related to alterations in skin t%rgor &edema'

    ($ter ) ho%rs o$ n%rsing intervention *atient +ill maintain an inta"t skin

    ,inspe"t skin $or "hanges in "olo%rt%rgor- vas"%laritynote redness ,monitor $l%id intake and hydration o$ skin and m%"o%s membranes

    ,,indi"ates areas o$ poor "ir"%lation/breakdo +n that may lead to in$e"tion ,dete"ts presen"e o$ dehydration or over hydration that a$$e"t "ir"%lation and tiss%e integrity at the "ell%lar level

    ($ter the n%rsing intervention +as done the patient maintain an inta"t skin

    ,inspe"t dependent areas $or edema. Elevate legs as indi"ate

    ,edemato%s tiss%es are prone to breakdo+n. Elevation promotes veno%s ret%rn- limiting veno%s stasis- edema $ormation ,prevents dire"t dermal irritation and promotes evaporation o$ moist%re on the skin ,lotions and ointment may be desired to relieve dry"ra"ked skin

    ,s%ggest +earing loose $itting "otton garments

    ,(pply "reams or ointments as pres"ribed

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