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bent, whereas
others find
relief when
supine with
pillows under
knees.
12) Encouraged
adequate rest periods.
® To prevent
fatigue.
Patient: X Medical diagnosis: Cellulitis in right lower extremity and Diabetes Melllitus type 2.
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Address: Bitaog, Bansalan, Davao Su Attending physician: Dr. Sarno
Age: 79 yrs. Chief complaint: Wound Swelling at Right Leg
Impaired Skin Integrity
DATE/TIME CUES NEED NURSING GOAL OF CARE NURSING EVALUATION
DIAGNOSIS INTERVENTIONS
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Celsius A associated with slow, prevent skin ® Uremic skin does not
@ B progressive glucose breakdown. have the usual amount a.) absence of dry
-dry and scaly O intolerance, the onset of oil because of skin
1pm skin noted L of type 2 diabetes decreased sweat and oil
I may go undetected glands. b.) lesions without
- non- healing C for many years. If complications.
wound right symptoms are 4. Instruct patient to
foot P experienced, they are wear loose- fitting b.) Demonstrate
A frequently mild and clothing when edema is behavior or
-dependent and T may include fatigue, present or either shorts. technique to
need assistance T irritability, polyuria, ® Restrictive clothing prevent skin
in doing daily E polydypsia, skin can increase risk of break down.
activities. R wounds that heal skin breakdown. However, display
N poorly and blurred timely healing of
vision. 5. Stress the skin is absent.
importance of not
scratching skin and of
keeping fingernails
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