Date Cues Needs Nursing Diagnosis Planning Nursing Intervention Evaluation

Septembe Subjective: N Risk for impaired skin Within four 1. Monitor VS. GOAL MET.
r “Naunsa naman U integrity related to hours of nursing Rationale: To obtain baseline data. After four hours of
9, 2010 intawon ning akong T alterations in skin care, patient will nursing care, the
@ 7-3 pamanit labaw na sa R turgor due to edema be able to 2. Inspect skin for changes in color, patient was able to
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shift katiilan nko, katol- secondary to CRF. demonstrate turgor, and vascularity. Note redness demonstrate
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katol pa jud,” as behaviors/ and excoriation. behaviors/techniqu
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verbalized by the O techniques to Rationale: Indicate areas of poor es to prevent skin
patient. N prevent skin circulation/breakdown that may lead breakdown/injury.
A breakdown/injur to decubitus formation/infection.
Objectives: L y.
 Dry Skin 3. Monitor fluid intake and hydration
Noted M Scientific Basis: of skin and mucous membranes.
 Skin Turgor E Skin is the primary Rationale: Detects presence of
Noted T defense of the body; it dehydration or overhydration that
 Scratching A protects the body affects circulation and tissue integrity
B against infections and
Of Skin at the cellular level.
O diseases brought about
Noted by the invasion of
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I microbes in the body. 4. Inspect dependent areas for edema.
C A normal skin is moist Elevate legs as indicated.
and intact; dryness of Rationale: Decrease pressure on
P the skin is more prone edematous, poorly perfused tissues to
A to friction that may reduce ischemia.
T result to impairment of
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the skin integrity as
compared with a moist 5. Change position frequently, move
E patient carefully, pad bony
skin.
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prominences and place elbow/heel
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protectors.
Rationale: To prevent pressure sores.
6. Provide soothing skin care. Restrict
use of soaps. Apply ointments or
creams.
Rationale: Decreases itching and
relief of dry, cracked skin.

7. Keep linens dry and wrinkle-free.

Rationale: Reduces derma irritation
and risk of skin breakdown.

8. Investigate reports of itching.

Rationale: Itching can occur because
the skin is an excretory route for waste
products.

9. Recommend patient use cool moist

compresses to apply pressure on
pruritic areas. Keep fingernails short
and encourage use of gloves during
sleep if needed.
Rationale: Alleviates discomfort and
reduces risk of dermal injury.

10. Suggest wearing loose-fitting

cotton garments.
Rationale: Prevents direct dermal
irritation and promotes evaporation of
moisture on the skin.