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Client s Initials: __G.

M________ Room # __588______ Student__Shelli Pryor Nursing Diagnosis and Assessment Data: Risk for impaired skin integrity r/t immobility painful grimace from pt with Q 2 hour change of position ,and reddened area of pt s buttocks Subjective: pt demonstrated discomfort with grimacing when moving pt for Q 2 hr position changes Pt refusal to allow pillows to be placed under legs to reduces swelling 1. Pt will demonstrate skin integrity free of pressure ulcers during her stay in hospital Goal and Outcomes: GOAL: Pt will have no impaired skin integrity Outcomes: (Measurable outcomes):

Diagnosis: Community Acquired Pneumonia ___________________________________ G Nursing Measures:

Rationale:

Evaluation of Outcomes:

1. Monitor client for


skin breakdown Q 2 hrs looking for redness, edema, ecchymosis, warmth or pain of skin. 2. Turn pt Q 2 hours 3. Monitor bedding for friction or shearing 4. Make turning chart for staff to adhere too.

1. Systematic inspection can


identify impending problems early. 2. Positioning interventions reduce pressure and shearing force to the skin 3. Making sure bedding sheets and materials around body are not causing friction prevents possible problems 4. Making a chart for future shifts allows for all staff members to stay on track and insures pt s safety and skin integrity Pt was turned q 2 hrs

Objective: Pt is physically immobile and unable to get out of bed due to age ( 94) Area of Pt s buttocks reddened and warm to touch Pt is incontinent of bowels and bladder, leading to excessive moisture of skin Pt is extremely lethargic and non

Pt demonstrated no skin breakdown throughout 8 hr shift

Pt was cleaned

compliant and disoriented

2.The Pt skin will remain dry and free from moisture within the perineum and sacral area with each bowel or bladder movement changing

1. Wash perineum with


liquid soap that will not alter skin pH and sacral area 2. Apply protective barrier perineal and sacral area 3. Maintain constant check on pt to make sure she is dry and clean 4. Change pt immediately if she has bowel or bladder movement 1. Maintaining proper PH allows proper skin nutrition and the skin is the first line of defence 2. Protective barriers prevent moisture from breaking down the skin when incontinence in an issue and can t be prevented. 3. Moisture softens the skin and cases a break in the skin integrity. 4.Quick intervention prevents the moisture of breaking through skin and allow the barrier to work long enough to work

and dried after each bowel and bladder movement

Moisture Protective barrier was used with each bowel and bladder changing

1. Drinking plenty of fluid helps in


maintaining healthy skin

1. Encourage pt to
drink at least 1500-2000 ml of fluid per day 2. Encourage pt to eat her complete meal teaching importance of protein and fluid intake. 3. Monitor pt weight daily to access for daily

2. Nutrition is fundamental to
normal cellular integrity and tissue repair.

3. pt will eat diet high in protein and carbohydrates and fluids (at least 1500 to 2000 ml per 24 hours) daily

3. Maintaining proper weight is a


good assessment of proper nutrition

4. Making sure pt is always


putting out as much as they are putting in to make sure they have proper tissue

Goal was not met pt was place on NPO until repeat swallow test due to previous failed swallow test the previous day. Will continue with nutritional plan when NPO status is lifted if pt remains NPO adequate nutrition with be give intravenously

nutrition 4. Monitor pt Intake and Output

profusion