ASSESSMENT

EXPLANATION OF THE PROBLEM Paralyzed

OBJECTIVES Short term: After 24 of Nursing Intervention, the wa t ch er s will be able to verbalize u n d e r s t a n d i n g o f individual fa ct ors that contribute to possibility o f s k i n i n t e g r i t y impairment and takes s t e p s possible to correct t h e situation of the client .

INTERVENTION 1. Assess skin routinely, noting moisture, color, and elasticity. 3. Observe for reddened/blanched areas or skin rashes, and institute treatment immediately. 4. Massage bony prominences and use proper positioning, turning, lifting, and transferring techniques when moving client. 5. Provide clothing/covers. adequate

RATIONALE May indicate particular vulnerability

EVALUATION Short term: Goal met After 24 of Nursing Intervention, the wa t ch er s wer e be able to verbaliz e u n d e r s t a n d i n g o f individual fact ors that contribute to possibility o f s k i n i n t e g r i t y impairment and took s t e p s possible to correct t h e situation of the client .

S:  merong namumula sa likod nya, as verbalized by the patients watcher O: >Bedridden >Redness noted on area of the sacrum >Patient is unable to turn herself in bed >Decreased Range of Motion Exercise >Diaphoresis noted > bedridden

preasure to Bony areas of body

Reduces likelihood of progression to skin breakdown.

Decreased blood flow to bony areas of body specially the sacrum

To prevent friction or shear injury.

Plus Constant Friction with bed linens and Sweating Redness on the area of the sacrum Long term: After 2-3 days of Nursing Intervention Pt will not show signs of infection or worsening of skin breakdown such as redness or swelling. 1) Pts skin will not have increased redness or swelling over bony prominences within the duration of the duty 2) Pts stage 1 pressure ulcers will not have increased redness or any skin tears 23 Pt stage 1 pressure ulcer will have decreased in size and amt within the duration of the duty

To prevent vasoconstriction.

A> Risk for Impaired Skin Integrity r/t decreased range of motion, inability to turn self in bed secondary to ______ and increased shearing forces and pressure on sacrum secondary to necessity of keeping client in

Risk for Impaired skin integrity

6. Keep bed linens dry and wrinkle free.

To reduce chances of acquiring bedsores.

7. Provide protection by use of pads, pillows, foam mattress or water bed.

to increase circulation and limit/eliminate excessive tissue pressure.

Long term: Goal Met After 2-3 days of Nursing Intervention Pt will not show signs of infection or worsening of skin breakdown such as redness or swelling. :1) Pts skin did not have increased redness or swelling over bony prominences within the duration of the duty 2) Pts stage 1 pressure ulcers did not increased redness or any skin tears 3) Pt stage 1 pressure ulcer will have decreased in size and amt within the duration of the duty

semi-Fowler's position to avoid aspiration during weaning of tracheostomy tube

8. Log rolling done q1o

reduce chances of acquiring bedsores and limit/eliminate excessive tissue pressure. To maintain general good health and skin turgor.

9. Emphasize importance of adequate nutritional/fluid intake.

10. Suggest use of lotion. To decrease irritable itching. 11. Recommend nails short. keeping To reduce risk of dermal injury when severe itching is present