Pines City Colleges

College of Nursing
(Owned and Operated by THORNTONS INTERNATIONAL STUDIES, INC.)
Tel. nos.: (074) 445-2210, 445-2209 Fax: (074) 445-2208
www.pcc.edu.ph

NAME: PILPILING, JAREN A.

YEAR/SECTION/ GROUP: BSN 1-05 GROUP 15 DATE: August 11, 2021

NURSING CARE PLAN

PROBLEM: RISK FOR IMPAIRED SKIN INTEGRITY

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective After 3 days of nursing Independent: After 3 days of nursing
“awan mariknak nu intervention, the client will: >Elevate lower extremities periodically, if >Enhances venous return. Reduces intervention, the client was
masagidak ken hanak tolerated. edema formation. able to:
makakuti” as verbalized by >I d e n t i f y risk factors
the patient of acquiring impaired skin >Massage and lubricate skin with bland >Enhances circulation and protects > T o identify risk factors
>Risk for impaired skin integrity lotion/oil. Protect pressure points by use of skin surfaces, reducing risk of of acquiring impaired skin
Objective integrity related to heel/elbow pads, lamb’s wool, foam padding, ulceration. integrity
-Skin tears immobility and sensory >U s e o f preventive egg-crate mattress.
-Bed sores loss. measures to maintain good skin >Able to utilize
-Redness in boney part integrity >Reposition frequently, whether in bed or in the preventive measures to
-Presence of edema sitting position. Place in prone position >Improves skin circulation and reduces maintain good skin integrity
>Verbalize periodically. pressure time on bony prominences.
understanding of necessary  >Able to
>Wash and dry skin, especially in high >Clean, dry skin is less prone to verbalize understanding
moisture areas such as perineum. excoriation/ breakdown. about the importance
of interventions

Collaborative:
>Avoid/limit injection of medication below >Reduced circulation and sensation
the level of injury. increase risk of delayed absorption,
local reaction, and tissue necrosis

>Stimulates circulation, enhancing

>Encourage continuation of regular exercise cellular nutrition/ oxygenation to
program. improve tissue health.

PROBLEM: RISK FOR FLUID VOLUME DEFICIT


ASSESSMENT
Subjective
“agkakapsot ak ngy, ksla ak
py agsasadut ken 3-4 days
ko narkna ti sakit bagik ken
fever.”
“kanayun ak makaininum
danum ngm ipaparwar ku
mtlng ta kanayun ak ag
sarwa ken agbawas kt watery
dy takki.”
Objective
- Mild fever: 38.6°C
(101.5°F)
- Pulse: 86 BPM
-Respirations: 24/minute
-Scant urine output
-BP: 102/84 mm Hg
-Dry oral mucosa, furrowed
tongue, cracked lip
Pines City Colleges
(Owned and Operated by THORNTONS INTERNATIONAL STUDIES, INC.)
Tel. nos.: (074) 445-2210, 445-2209 Fax: (074) 445-2208
NURSING PLANNING
DIAGNOSIS
After the nursing interventions,
the client will be able to:
- develop the desired Electrolyte
& Acid/Base Balance
-develop the desired Fluid
Balance
(24-hour intake and output
>Risk for Fluid Volume balance, urine specific gravity,
Deficit Related to Vomiting blood pressure, pulse, and body
and Diarrhea temperature, skin turgor and
moist mucous membranes
College of Nursing
www.pcc.edu.ph
INTERVENTION
>Assess the client’s skin turgor and mucous
membranes for signs of dehydration.
>Assess the volume and frequency of
vomiting
>Assess the consistency and number of
bowel movements.
>Assess the color and amount of urine.
>Assess the client’s PR and BP.
>Monitor BP for orthostatic changes
>Administer antiemetic medications as
ordered
RATIONALE
>A loss of interstitial fluid causes the
loss of skin turgor.
>Vomiting is associated with fluid
loss.
>Gastroenteritis is associated with an
increased frequency of very loose or
watery bowel movements.
>A decrease in urine volume and
concentrated urine, as evidenced by a
darker urine color, denotes fluid
deficit.
>A reduction in circulating blood
volume can cause hypotension and
tachycardia.
>Greater than 10 mm Hg: circulating
blood volume decreases by 20%.
Greater than 20 to 30 mm Hg drop:
circulating blood volume is decreased
by 40%.
> These drugs will reduce vomiting
and the risk for fluid volume deficit.
EVALUATION
>the patient was required
fluid replacement of a total of
5 liters.
>the patient’s blood pressure
increased to 122/74, pulse
rate decreased to a resting
level of 74, and respirations
decreased to 12/minute
>urine output increased as the
fluid was replaced and was
adequate at > 0.5 mL/kg/hour
by the time of discharge
>the patient had elastic skin
turgor and moist mucous
membranes and was taking
oral fluids and was able to
discuss symptoms of deficient
fluid volume that would
necessitate the patient calling
the health care provider.