ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
DEFINING NURSING DIAGNOSIS
CHARACTERISTIC
Subjective: Impaired Skin Integrity and
Peripheral Edema related
“Naga pamant-ol kag to compromised circulation
gamaga akong tuo nga tiil” secondary to pustular
as verbalized by the lesions, dry wound, and
patient. edema in both legs.
Objective: Rationale:
BP: 11/80 Defined as a disruption in
the normal skin structure
Temp.: 36.6 and function. It occurs
when the skin is
PR: 88
compromised in some way,
making it more vulnerable
RR: 20
to damage, injury, or
Oxygen Saturation: 97% breakdown.
Leg swelling and erythema References:
Pustular lesions at right Doenges, M. E.,
calf Moorhouse, M. F., & Murr,
A. C. (2022, October 19).
Dry wound at right foot Nurse’s Pocket Guide:
Diagnoses, Prioritized
(+) edema at both legs Interventions, and
Rationale 10th Editions
West Avenue, Molo, Iloilo City
NURSING CARE PLAN
OUTCOME NURSING RATIONALE EVALUATION
IDENTIFICATION INTERVENTIONS
Long Term: Independent:
Routine skin assessments Goals were partially met as
After four weeks of Perform a complete skin help determine progression the patient’s condition was
nursing interventions, the assessment and appropriate monitoring but edema was
pustular lesions and dry interventions for patient controlled and stabilize.
wound will be completely care. Monitor for impaired
healed, with no signs of skin integrity such as
infection and patient's redness, nonblanchable
peripheral edema will be skin, and open wounds.
consistently controlled,
with minimal fluctuations.
Severe edema can be
Short Term: documented as pitting on a
scale of 1+-4+ which is
After 1 week of nursing assessed by the depth of
Assess pitting edema
interventions, the patient indentation in the skin
will experience improved without rebound when
skin integrity, reduced applying pressure.
peripheral edema, and
effective pain management, Implement preventive
resulting in enhanced measures such as turning
comfort and mobility. and repositioning the
patient regularly, using
pressure-relieving devices,
Keep the skin clean and and providing adequate
dry skin hygiene. These actions
help maintain skin
integrity.
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
(Nurse’s Pocket Guide:
Diagnoses, Interventions &
Rationales) (10th ed.). F A
Davis Co.
Elevate edematous
extremities and reposition.
Note: Nursing Diagnosis
should be base from
(NANDA- Approved
Nursing Diagnosis)
Regularly assess and
document the patient's
fluid intake and output to
maintain adequate
hydration levels.
Educate the patient and
their family on the
importance of adhering to
the treatment plan, wound
care, medication
management, and lifestyle
modifications.
Encouraging the patient to
change positions, perform
range of motion exercises,
and walk when appropriate
helps prevent
complications like pressure
ulcers and deep vein
thrombosis. It also
enhances circulation and
respiratory function.
Dehydration can
exacerbate edema and
impair wound healing.
Informed patients are more
likely to actively
participate in their care and
follow recommendations.
This ensures timely
treatment of infections,
pain relief, and supports
the overall management of
the patient's condition.
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

Dependent:

Pantoprazole 40 mg/cap,
1 cap OD 30 mins before
breakfast

Clindamycin (Clindal)
300 mg, IV Q6H

Amlodipine 5mg 1 tab OD

Telmisartan 40 mg 1 tab

Piperacillin tacobactam
4.5 IV Q6H ANST

DRUG STUDY

Classification and Indication and Side Effect or Adverse

Name of Drug Special Precautions Nursing Responsibility
Mechanism of Action Contraindication Effect

Generic Name: Classification: Indication: Adverse reactions: Use cautiously in:  Observe 10
Pantoprazole Rights of giving
Proton Pump Inhibitor Erosive esophagitis CNS: dizziness, headache  Severe hepatic
caused by gastro
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

Brand: Protonix Mechanism of Action: esophageal reflux CV: chest pain disease medications
disease (GERD)  Atrophic gastritis  Assess for
Dosage: 40 mg Reduces gastric acid EENT: rhinitis
secretion and increases Contraindication: with long term symptomatic
Route: Per Orem gastric mucus and GI: vomiting, diarrhea, use improvement
bicarbonate production, Hypersensitivity to drug abdominal pain, dyspnea  Increased risk of  Monitor blood
Frequency: 30 min before or any substituted
creating protective osteoporosis- glucose level in
breakfast benzimidazole Metabolic:
coating on gastric related hip, wrist, diabetic patient
hyperglycemia
Timing: 5:30 AM mucosa.
or spine fractures  Explain that
Musculoskeletal: hip, with long-term antacids don’t
wrist, spine fractures
(with long term daily use or multiple affect drug
use) daily doses absorption.
 Concurrent use of  As appropriate,
Skin: rash, pruritus atazanavir, review all other
nelfinavir, or significant
methotrexate adverse reactions
 Pregnant or and interactions,
breastfeeding especially those
patients related to the
 Children drugs and tests
mentioned above.