Impaired Skin Intergrity Of Pegnant Woman

Assessment Subjective: “Minamanas ang daliri ko tignan mo oh” as verbalized by the client.

Objective: Edema +4 in the index finger. Ring cannot fit anymore into the index finger. Skin pigmentation change. Disruption of skin surface. When palpated tenderness occur.

Nursing Diagnosis

Scientific Explanation

Impaired skin Edema is caused by integrity reduce circulation related to into the extremities reduced due to uterine circulation pressure and general into the fluid retention. extremities as evidence by Reference: maternal edema on her and child volume one finger 5th edition chapter 11 page 285

Planning

Intervention

Scientific Rationale

Independent: Long term outcome: After 7 days of nursing intervention the client will be able to • Display timely healing of skin lesion, pressure sores without complication • Maintain optimal nutrition/physical well-being Short outcome: After 2 days of nursing intervetion, the client will be able to: • Verbalize feelings of increased self-esteem and ability to manage situation

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Assist the client in understanding and the following medical regimen and developing program of preventive care and daily maintaining.

•

Emphasize the importance of proper fit clotting

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Put feet high whenever possible

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Take regular breaks from sitting or standing

Partially achieved •

Enhances commitment to plan optimizing outcomes

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Impede lower extremity circulation and venous return.

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To reduce pressure to veins.

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A short walk every so often will help keep blood circulating.

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To evaluate actual/potential

collaborative: •

Assess blood supply and sensation of affective area.

Evaluation

The client was able to Verbalize feelings of increased selfesteem and ability to manage situation. “ah, kaya pala ganito, alam ko na ang mga gagawin ko ngayon”, as verbaluzed by the patient.

for impairment of circulation to lower extremities. Reference: NANDA and Maternal and child volume 15th edition