NURSING CARE PLAN

Name of Patient: __Cassandra Salisay ___________________ Age/Sex: ___78 / F__ Room and Bed no.: _329-2_____
Chief Complaint: c/o dry mucous membrane & poor skin turgor_ Diagnosis: __Dehydration ________________________
Attending Physician: __Dr. D. Hamato____________________

Nursing Planning of
Date/Time Cues/Clues Needs Patient Outcome Implementation Evaluation
Diagnosis Intervention
August 25, Subjective: Nutritional- Risk for After 48 hours of 1. Urge the patient to 1
2021 - “I hate Metabolic Impaired Skin comprehensive consume the prescribed
water and Pattern Integrity as nursing amount of oral fluids.
3 PM evidenced by interventions, the
don’t drink it
altered fluid patient will exhibit R: Elderly patients may
much.”
volume, dry improved skin need constant prompt as
mucous intactness as sensation of thirst
membrane, evidenced by decreases with age. Oral
Objective:
and optimal body fluid fluid replacement is a
- 78 years cost-effective method in
old decreased volume, moist
skin turgor. mucous maintaining hydration.
- with
physician’s membrane, and
order to increased skin
increase PO turgor.
2. Encourage a hydrating 2
intake into Rationale: diet, as ordered.
2500 cc/day This aids in R: Sufficient nutrition
- dry formulating maintains body fluid
mucous appropriate volume and skin integrity.
membrane nursing
- poor skin actions to
turgor assist the
client in
minimizing
the risk for
impaired skin 3. Clean, dry, and
integrity and moisturize the skin 3
in restoring particularly over bony
the client’s prominences, as
health into an indicated.
optimum R: Skin moisturization
level from prevents further
dehydration. desiccation and promotes
suppleness.

4. Cover the patient with

light sheets. 4
R: This provides a
comfortable environment
that prevents overheating
and further fluid loss.

5. Assist the patient in

position changes in the
5
bed and chair every 15
minutes.
R: Frequent change of
position reduces
pressure to skin and
improves circulation.
 6. Render health
Reference: teachings about 6
Wayne, G. hydration, oral hygiene,
(2019). Risk and proper skin care.
for impaired R: Health education
skin integrity enhances sense of self-
nursing care efficacy in the prevention
plan. and management of the
Nurselabs. condition.
Retrieved
online from
https://nurses
labs.com/risk-
for-impaired-
skin-integrity/