Cues Diagnosis Planning Intervention Rationale Evaluation

Objectives: Impaired bed after 8 hour of >assist with >to maximize after 8 hour of
Impaired mobility nursing treatment to potential for nursing
ability to intervention, client underlying mobility and intervention, client
turn from will be able to: condition function was able to:
side to side >maintain position >maintain position
of function and kin >change client >to prevent of function and
Impaired integrity as position at least redness and skin integrity as
ability to evidence by every 2 hours. pressure ulcer evidence by
reposition absence of and improve absence of
self on bed contractures and circulation contractures and
pressure ulcers. pressure ulcers.
>perform and >to reduce
encourage regular pressure on
skin examination sensitive areas
for reddened or and prevent
excoriated areas. development of
problems with
skin or tissue
integrity

>provide or assist >to maintain joint

with daily range of mobility, improve
motion circulation, and
intervention(active prevent
/ passive) contractures
 Cues Diagnosis Planning Intervention Rationale Evaluation

Objective: Risk for impaired After 7 hours of >determine clients >In older adults After 7 hours of
skin integrity nursing age there is decrease nursing
related to physical intervention the epidermal intervention the
immobilization client will be able regeneration, client will be able
to maintain skin fewer sweat to maintain skin
integrity as glands, and less integrity as
evidence of subcutaneous fat evidence of
absence of and elastin and absence of
redness to bony collagen causing redness to bony
extremities skin to become extremities
thinner, drier, and
less responsive to
pain sensation

>review laboratory >to evaluate or

result (e.g. ability to heal
hgb/hct, blood
glucose, albumin,
protein)

>perform routine >systemic

skin inspection, inspection can
assessing color, identify
temperature, developing
surface changes, problems and
and texture promote early
intervention, thus
reducing
likelihood of
progression to
skin breakdown
>handle client >skin of older
gently adult is already
thin, less elastic,
and prone to
injury, such as
bruising and skin
tears.

>move client side >to promote and

to side for atleast maintain blood
every 2 hour circulation, and
prevent redness
and pressure
ulcer