Date

July
18
2016
311

Cues

Needs

Objective:
1) Prolonged
lying on bed
2) Patients
inability to turn
to side to side.
3) Scaly/flaky
skin
4) Right Sided

N
U
T
R
I
T
I
O
N
A
L
M
E
T
A
B
O
L
I
C

Weakness
(Hemiparesis)

P
A
T
T
E
R

Diagnosis

Objectives

Interventions

Risk

for At the end of the 1) Inspect skin,

noting bony
impaired skin 8-hour
shift,
prominence,
integrity
r/t patient
will
presence of edema,
prolonged bed maintain
skin
areas altered
circulation/pigmen
rest
and integrity.
tation, or
decreased tissue
obesity/emaciation
perfusion.
2) Provide gentle
massage around
reddened or blanched
areas.
3) Re position patient
every 2 hours.
4) Provide frequent
skin care; minimize
contact with
moisture/excretions
5) Provide alternating
pressure
6) Maintain adequate
nutrition and
hydration
7) Encourage use of
lift sheet to move
patient and discourage
caregiver from

Rationale

Evaluation

1. Skin is at risk
because of
impaired
peripheral
circulation,
physical
immobility, and
alterations in
nutritional status.
2. Improves blood
flow, minimizing
tissue hypoxia.
3. Reduces pressure
on tissues,
improving
circulation and
reducing time any
one area is
deprived of full
blood flow.
4. Excessive dryness
or moisture
damages skin and
hastens
breakdown.
5. Reduces pressure
to skin, may
improve
circulation.

Goal met.
At the end of
the

8-hour

nursing

care,

patients

skin

remained intact.

elevating HOB
repeatedly.
8) Monitor skin
condition at least once
a day for color or
texture changes,
dermatological
conditions, or lesions.
9) Always keep linens
of the bed and
mattress wrinkle free.
10) Place a pillow or
gauze on bony
prominences when
patient is lying on his
back.

6. Hydrated skin is
less prone to break
down.
7. These measures
reduce shearing
forces on the skin.
8. Systemic infection
can identify
impending
problems early.
9. Keeping the bed
wrinkle free
lessens the
probability of
developing
pressure sores
10. Placing a gauze or
pillow will lessen
the pressure in
accumulating on
the bony
prominences.