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Chinese General Hospital College of Nursing

NURSING CARE PLAN


PATIENT’S NAME:Aurora Dino AGE: 98 years old DIAGNOSIS: Lid lag, Senile, Hypersomnia

ASSESSMENT NURSING INFERENCE GOAL INTERVENTION RATIONALE EVALUATION


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

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