with knees

bent, whereas
others find
relief when
supine with
pillows under
knees.

12) Encouraged
adequate rest periods.
® To prevent
fatigue.

Patient: X Medical diagnosis: Cellulitis in right lower extremity and Diabetes Melllitus type 2.

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 Address: Bitaog, Bansalan, Davao Su Attending physician: Dr. Sarno
Age: 79 yrs. Chief complaint: Wound Swelling at Right Leg
Impaired Skin Integrity
DATE/TIME CUES NEED NURSING GOAL OF CARE NURSING EVALUATION
DIAGNOSIS INTERVENTIONS

F Subjective: N Impaired skin Within our 8 hours 1. Established rapport February

E “wala pa jud U integrity related to span of care, the patient to our patient. 06,
B naayo akong T non-healing wound at will be able to maintain ® To gain their trust 2010
R samad” as R right foot secondary optimal skin integrity and cooperation.
U verbalized by I to Diabetes Mellitus as evidenced by: At 1:00 pm
A the patient. T 2. Inspect skin surfaces
R I ® Type 2 diabetes a. absence of dry or pressure points GOAL
Y O occurs most skin routinely. PARTIALLY MET!
Objective: N commonly in people b. display timely ® Edematous tissues
- warm skin in A older than 30 years healing of skin are more prone to After our 8 hours
06, lower L who are obese, lesions without breakdown and to the span of care our
extremities - although its incidence complications formation of decubitus. patient was able to
M is increasing in c. Demonstrate maintain optimal
2010 -temperature of E younger adults. behavior or 3. Assess for dry, scaly skin integrity as
36.6 degrees T Because it is technique to skin. evidenced by:

115
 Celsius A associated with slow,
@ B progressive glucose
-dry and scaly O intolerance, the onset
1pm skin noted L of type 2 diabetes
I may go undetected
- non- healing C for many years. If
wound right symptoms are
foot P experienced, they are
A frequently mild and
-dependent and T may include fatigue,
need assistance T irritability, polyuria,
in doing daily E polydypsia, skin
activities. R wounds that heal
N poorly and blurred
vision.
prevent skin ® Uremic skin does not
breakdown. have the usual amount a.) absence of dry
of oil because of skin
decreased sweat and oil
glands. b.) lesions without
complications.
4. Instruct patient to
wear loose- fitting b.) Demonstrate
clothing when edema is behavior or
present or either shorts. technique to
® Restrictive clothing prevent skin
can increase risk of break down.
skin breakdown. However, display
timely healing of
5. Stress the skin is absent.
importance of not
scratching skin and of
keeping fingernails
116