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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
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
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
 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. treatment plan  Immobility is periods of time. itching is present ambulation as tolerated  to enhance venous return . 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. 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. results in an the greatest risk those with increased number factor in skin edema. risk factors protective protect from present. weight shifting. 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. ischemia to skin is high as a result injured. extremities when  to reduce risk and other sitting of dermal injury  encourage when severe devices.  recommend turgor specialty beds elevation of lower and mattresses.

and reduce edema formation  to enhance circulation .