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Assessment SUBJECTIVE: Namamanas ang kamay at paa ko as verbalized by the patient b!


Diagnosis #isk $or skin integrity related to alterations in skin t%rgor &edema'

Planning ($ter ) ho%rs o$ n%rsing intervention *atient +ill maintain an inta"t skin

Intervention ,inspe"t skin $or "hanges in "olo%rt%rgor- vas"%laritynote redness ,monitor $l%id intake and hydration o$ skin and m%"o%s membranes

Rationale ,,indi"ates areas o$ poor "ir"%lation/breakdo +n that may lead to in$e"tion ,dete"ts presen"e o$ dehydration or over hydration that a$$e"t "ir"%lation and tiss%e integrity at the "ell%lar level

Evaluation ($ter the n%rsing intervention +as done the patient maintain an inta"t skin

,inspe"t dependent areas $or edema. Elevate legs as indi"ate

,edemato%s tiss%es are prone to breakdo+n. Elevation promotes veno%s ret%rn- limiting veno%s stasis- edema $ormation ,prevents dire"t dermal irritation and promotes evaporation o$ moist%re on the skin ,lotions and ointment may be desired to relieve dry"ra"ked skin

,s%ggest +earing loose $itting "otton garments

,(pply "reams or ointments as pres"ribed