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    Impaired Skin Integrity

    Uploaded by

    jessa mae

    Copyright:

    © All Rights Reserved
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    Impaired Skin Integrity

    Uploaded by

    jessa mae
    13 views3 pages

    Original Title

    Impaired skin integrity

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    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
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    Download as pdf or txt
    13 views3 pages

    Impaired Skin Integrity

    Uploaded by

    jessa mae

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 3

    Jessa Mae G.

    Felisco

    Name of Patient: Argallon, Maria Gopinath Araneta Rm 336B Age: 44 yrs old

    Assessment Nursing Expected Nursing Interventions Rationale Evaluation


    Diagnosis Outcomes

    Subjective: Impaired Within 8 hours of Independent:


    Skin Integrity nursing - Conduct a - To monitor
    “Nakuyawan man r/t decreased interventions, patient thorough skin particular areas
    ko aning aking tissue will be able to assessment with wound and to
    samad basin perfusion maintain intact skin prevent further
    mugrabe ni ba secondary to integrity as worsening of the
    tungod sa DM type 2 evidenced by: condition
    infection”
    - No signs of - Assess skin - To monitor for any
    Objective: infection turgor decrease tissue
    noted perfusion
    - Open - Demonstratio
    wound on n of effective - Assess mobility - To provide
    the upper wound care status of the appropriate
    and lower - Verbalize patient activities to prevent
    extremitie signs and further skin
    s with symptoms of breakdown caused
    yellowish infection and by pressure and
    discharge necrosis shearing
    and foul - Verbalize
    smell proper - Monitor patient’s - Diabetes may
    - Redness nutrition for blood glucose increase chances
    around wound of infection and
    wound healing contribute to severe
    site - Timely complications by
    - Itchiness healing of slowing down
    around wounds healing process
    wound without - Position the - To prevent or
    site complication patient relieve pressure
    - Skin warm s comfortably
    to touch
    - Poor skin - Keep the skin - Monitor discharge
    turgor >3 clean and dry from wound and
    secs change linens and
    diaper to avoid
    Laboratory irritation of the skin
    Results due to secretions

    RBS: 125 mg/dL - Encourage proper - To contribute to a


    nutrition much faster healing
    Gram Stain: process. Protein
    PMN/Pus Cells: intake, vitamins A,
    Many C and E and zinc
    Epithelial: Few support wound
    Rare Gram: (+) healing
    diplococci
    - Educate on - To prevent
    Albumin serum: diabetic unnoticed wounds
    1.90 neuropathy and that may lead to
    importance of infection
    Vital signs daily check
    T: 36.1
    B/P: 120/65 - Educate about - To monitor wound
    mmHg the signs and and prevent further
    O2 sat: 97% symptoms of infection
    RR: 18 cpm infection
    PR: 70 bpm
    - Educate about - To promote
    proper wound independence and
    care reduce risk of
    infection
    Dependent:
    - Administer - To prevent/treat
    antibiotics as infection
    prescribed by the
    doctor

    - Provide wound - To promote wound


    dressing as healing and monitor
    ordered by the for any signs of
    doctor infection

    Collaborative:
    - Collaborate with - To promote health
    the dietitian about nutrition and
    the appropriate facilitate hydration
    diet for a faster healing
    process

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