Assessment Nursing Diagnosis Background

Knowledge
Planning Nursing
Intervention
Rationale Evaluation

Subjective Cues:
Hindi ko
maigalaw ang
aking katawan
baka magkasugat
daw ako, as
verbalized by the
patient.

Objective Cue:
Weak
Poor skin
turgor
On complete
bed rest
Immobile

Risk for impaired
skin integrity
related to
inadequate
circulation
secondary to
immobility.

Immobility

Pressure applied
to soft tissue

Complete or
partially
obstructed blood
flow to the tissue.

Shear or friction

Pressure ulcers

Within 8 hours of
nursing
interventions the
patient will:
1. Identify
individual risk
factors.
2. Verbalize
understanding
of treatment
needs.
3. Participate to
level of ability
to prevent
skin
breakdown.

Long term:

The patient will
not exhibit signs
of bedsores.

Independent:
1. Inspect all skin
areas, noting
capillary
blanching/refill
, redness, and
swelling. Pay
particular
attention to
back of head
and folds
where skin
continuously
touches.


2. Elevate lower
extremities
periodically, if
tolerated.

3. Massage and
lubricate skin
with bland
lotion/oil.
Protect
pressure
points by use
of heel/elbow
pads, lambs
wool, foam


1. Skin is
especially
prone to
breakdown
because of
changes in
peripheral
circulation,
inability to
sense
pressure,
immobility,
altered
temperature
regulation.
2. Enhances
venous return.
Reduces
edema
formation.
3. Enhances
circulation and
protects skin
surfaces,
reducing risk
of ulceration.
Tetraplegic
and paraplegic
patients
require

After 8 hours of
nursing
interventions the
patient:
1. Is able to
dentify
individual risk
factors.
2. Verbalized
understanding
of treatment
needs.
3. Participated
to level of
ability to
prevent skin
breakdown.




Aneliza B. De Vera BSN 3Y2-1B
padding, egg-
crate mattress.








4. Reposition
frequently,
whether in bed
or in sitting
position. Place
in prone
position
periodically.
5. Wash and dry
skin, especially
in high
moisture areas
such as
perineum.
6. Keep
bedclothes dry
and free of
wrinkles,
crumbs.
7. Provide kinetic
therapy or
alternating-
pressure
mattress as
lifelong
protection
from
decubitus
formation,
which can
cause
extensive
tissue necrosis
and sepsis.
4. Improves skin
circulation and
reduces
pressure time
on bony
prominences.


5. Clean, dry skin
is less prone to
excoriation/
breakdown.


6. Reduces/
prevents skin
irritation.


7. Improves
systemic and
peripheral
circulation and
decreases
indicated.



Dependent:
8. Avoid/limit
injection of
medication
below the
level of injury.




9. Encourage
continuation
of regular
exercise
program.

pressure on
skin, reducing
risk of
breakdown.

8. Reduced
circulation and
sensation
increase risk of
delayed
absorption,
local reaction,
and tissue
necrosis.
9. Stimulates
circulation,
enhancing
cellular
nutrition/
oxygenation to
improve tissue
health.