0 Bewertungen0% fanden dieses Dokument nützlich (0 Abstimmungen)
88 Ansichten3 Seiten
Elderly patients' skin is normally less elastic and has less moisture. Healthy skin varies among individuals but should have good skin turgor, feel warm and dry to touch, and have quick capillary refill. After a week of nursing intervention, the goal was fully met as evidenced by: a. Absence of bony prominence itchiness / irrita tion in the clients' skin.
Elderly patients' skin is normally less elastic and has less moisture. Healthy skin varies among individuals but should have good skin turgor, feel warm and dry to touch, and have quick capillary refill. After a week of nursing intervention, the goal was fully met as evidenced by: a. Absence of bony prominence itchiness / irrita tion in the clients' skin.
Copyright:
Attribution Non-Commercial (BY-NC)
Verfügbare Formate
Als DOC, PDF, TXT herunterladen oder online auf Scribd lesen
Elderly patients' skin is normally less elastic and has less moisture. Healthy skin varies among individuals but should have good skin turgor, feel warm and dry to touch, and have quick capillary refill. After a week of nursing intervention, the goal was fully met as evidenced by: a. Absence of bony prominence itchiness / irrita tion in the clients' skin.
Copyright:
Attribution Non-Commercial (BY-NC)
Verfügbare Formate
Als DOC, PDF, TXT herunterladen oder online auf Scribd lesen
DIAGNOSIS SUBJECTIVE: Risk for Increase age Short Term: Independent: Short Term: impaired skin After 6 hrs of nursing After 6 hrs of nursing “May makati.” as integrity intervention, the 1. Determine age. 1. Elderly patients’ intervention, the goal verbalized. related to client will show good skin is normally less was partially met as extremes of Reduced physical skin integrity as elastic and has less evidenced by: age activity. evidenced by: moisture, making Objective: for higher risk of Expected Outcome • Client is weak Expected Outcome skin impairment. c. Increased skin • Thin muscle a. Good skin turgor mass Muscle athropy turgor 2. Assess general 2. Healthy skin varies d. Decreased • Lid lag b. Decrease dry condition of the among individuals dry and scaly • No longer stand and scaly skin skin. but should have skin up on its own good skin turgor, • Poor skin turgor Weakness. Long Term: feel warm and dry to Long Term: After a week of touch, be free of After a week of • Dry and scaly nursing intervention, impairment, and nursing intervention, skin the client will no have quick capillary the was fully met as Decrease in longer be at risk of refill. evidenced by: physical mobility impaired skin integrity as 3. Specifically 3. Areas where skin is Expected Outcome evidenced by: assess skin over stretched tautly over a. Absence of bony bony prominence itchiness/irrita Prolonged bed Expected Outcome prominences. are at high risk of tion in the rest. a. Absence of skin breakdown clients’ skin. itchiness/irrita because the b. Sign of good tion in the possibility of hydration. clients’ skin. ischemia to skin as a Pressure sore. b. Sign of good result of hydration. compression of skin capillaries between a hard surface. Injury in the client. 4. Assess patient’s 4. Immobility is the Reference: ability to move greatest risk factor (e.g., shift in skin breakdown. Brunner and weight while Suddarth's sitting, turn over Textbook of in bed, move Medical-Surgical from bed to Nursing chair).
5. Increase tissue 5. Massaging the
perfusion by actual reddened area massaging may damage the around affected skin further. area.
6. Limit chair 6. Pressure over
sitting to 2 sacrum may exceed hours at any one 100 mm Hg pressure time. during sitting. The pressure necessary to close skin capillaries is around 32 mm Hg; any pressure greater than 32 mm Hg results in skin ischemia. 7. Clean, dry and 7. Smooth, supple skin moisturize skin, is more resistant to especially over injury. Talc can be bony inhaled and cause prominence, lung injury. twice daily or as indicated by incontinence or sweating. If powder is desirable, use medical grade cornstarch; avoid talc.
8. Encourage 8. Adequate hydration
adequate and nutrition help nutrition and maintain skin turgor, hydration. moisture, and suppleness, which provide resilience to damage caused by pressure.
9. Encourage 9. This will help in
client to wear preventing pressure socks while in on heels. bed STUDENT’S NAME: CHARLOTTE KAYE P. YU III-D/GROUP 5