Ncp Impaired Skin Integrity

Assessment Objective: >increase body temperature of 37.8C >flushed skin >warm to touch >decrease elasticity of the skin >dry skin >delayed capillary refill of four seconds >afebrile

Diagnosis >Impaired skin integrity related to altered body temperature

Planning

Intervention

Rationale

>At the end of the shift the patients’ capillary refill must be less than 4 seconds.

>Encouraged implementation and posting of a turning schedule, restricting time in one position to 2 hours or less

>To prevent discomfort and injuries to the body; to promote circulation

>Encouraged the SO to maintain functional body alignment of the patient like positioning it properly.

>Misalignment can lead to discomforts and injuries to joints, nerves or limbs.

>Assessed the patients ability to move

>Immobility is greater risk factor in skin breakdown

>Encouraged adequate hydration and nutrition

>Adequate hydration and nutrition helps maintain skin turgor, and suppleness.

>Clean, dry and moisture skin especially bony prominences

>Smooth and supple kin is more resistant to injury.

Evaluation Goal met as manifested by decreased in patient’s capillary refill from 4 secs. - 3 secs.