NURSING CARE PLAN

Assessment Nursing Scientific Planning Interventions Rationale Evaluation

Diagnosis Explanation
S: “lagi na lang Risk for Impaired Immobility, which Patient’s skin  establish rapport  to facilitate NPI Patient’s skin
akong nakahiga” Skin Integrity r/t leads to pressure, remains intact,  place the pt in a  to prevent remained intact,
as verbalized by prolonged bed shear, and friction, is as evidenced by comfortable position backaches or as evidenced by
muscle aches.
the patient. rest the factor most likely no redness over no redness over
 take and record  to note any
to put an individual bony vital signs significant changes bony
O: at risk for altered prominences and that may be brought prominences and
 Conscious and skin integrity. absence of skin about by the absence of skin
coherent Advanced age; the breakdown  Determine age. disease breakdown
normal loss of  Elderly patients’
 drowsy on skin is normally less
appearnace elasticity; inadequate
elastic and has less
 c sunken nutrition; moisture, making
eyeballs environmental for higher risk of
moisture, especially  Assess general skin impairment.
 c body condition of skin.  Healthy skin
from incontinence;
weakness varies from
and vascular
 restless insufficiency individual to
 c poor individual, but
potentiate the effects should have good
appetite; of pressure and turgor, feel warm
consumed ¼ of hasten the and dry to the
the food served development of skin touch, be free of
 c limited ROM breakdown. Groups  Specifically assess impairment, and
skin over bony have quick capillary
 ambulatory c of persons with the prominences refill (<6 seconds).
assistance highest risk for  Areas where skin
altered skin integrity is stretched tautly
are the spinal cord over bony
injured, those who prominences are at
higher risk for
are confined to bed
breakdown because
 or wheelchair for the possibility of
prolonged periods of ischemia to skin is
high as a result of
time, those with compression of skin
 Assess patient’s
edema, and those ability to move. capillaries between
who have altered a hard surface and
sensation that  Reassess skin the bone.
triggers the normal often and whenever  Immobility is the
protective weight the patient’s greatest risk factor
condition or in skin breakdown.
shifting. Pressure
treatment plan  The incidence and
relief and pressure results in an onset of skin
reduction devices for increased number of breakdown is
the prevention of risk factors. directly related to
skin breakdown  encourage change the number of risk
include a wide range of position in a factors present.
regular basis
of surfaces, specialty
 provide adequate  to prevent
beds and mattresses, clothing/covers; pressure to certain
and other devices. protect from drafts parts of the body
Preventive measures  emphasize  to prevent
are usually not importance of vasoconstriction
reimbursable, even adequate nutritional/
though costs related fluid intake  to maintain
 recommend general good health
to treatment once keeping nails short and skin turgor
breakdown occurs
are greater.  to reduce risk of
 recommend dermal injury when
elevation of lower severe itching is
extremities when present
sitting  to enhance
 encourage venous return and
ambulation as reduce edema
tolerated formation

 to enhance
circulation