Risk For Impaired Skin Integrity And Readiness For Enhanced Power

ASSESSMENT Subjective: “Lagi siyang nakahiga”, stated by the daughter

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

Risk for Skin Integrity r/t physical immobility

Decreased muscle strength ↓ Body weakness

Objective: -neuromuscular impairment

PLANNING Short term: After 8hours of nursing intervention, the client/SO will be able to verbalize understanding of treatment/therapy regimen

↓ Irritability

-physical immobility ↓ Physical immobility ↓ Risk for skin integrity

*Medical-Surgical Nursing 11th Edition; Brunner & Suddarth”s

Long term: After 2days of nursing intervention, the client/SO will be able to demonstrate behaviors/technique s to prevent skin breakdown

INTERVENTION

SCIENTIFIC RATIONALE

-Assess skin routinely, noting moisture, color, and elasticity

-this may indicate particular vulnerability

-Note presence of conditions/situations

-that may impair skin integrity

-Observe for reddened/blanched areas or skin rashes, and institute treatment immediately -Provide adequate clothing/covers; protect from drafts -Emphasize importance of adequate nutritional/fluid intake

-Reduces likelihood of progression to skin breakdown

-To prevent vasoconstriction -To maintain general good health and skin turgor

*Nursing Care Plans;7th Edition;Doenges,Mo orehouse,Murr

EVALUATION Achieved The client/SO was able to do therapeutic regimens to prevent skin breakdown

ASSESSMENT Subjective:

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

PLANNING

Readiness for enhanced power

A pattern of participating knowingly in change that is sufficient for well-being and can be strengthened.

Short term: After 8hours of nursing intervention, the client/SO will be able to verbalize knowledge of what changes he wants to make

Objective: -having selfperception

Long term:: After 2days of nursing intervention, the client/So will be able to state readiness to take power over own life

-indicate support sufficient

*Nurse’s Pocket Guide 11th Edition; Doenges, Moorhouse, Murr

INTERVENTION

SCIENTIFIA RATIONALE

EVALUATION

-Assess degree of Mastery client has exhibited in his life

-Helps client to understand how he has functioned in the past & what is needed to improve

Achieved The client/SO was able to express readiness of enhanced power

-Provide accurate verbal & written information about what is happening & discuss with client

-Reinforces learning & promotes selfpaced review

-Discuss importance of client paying attention to nonverbal communication

-Messages are often confusing/misinterpre ted when verbal and nonverbal communications are not congruent

-Help client learn to problem solve differences

-Promotes win-win solutions *Nursing Care Plans;7th Edition;Doenges,Mo orehouse,Murr