Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

Pt did not talk during shift

Objective

Pt had skin break down on legs and toes. Pt skin was very cool and dry and flaky. Pt had exudate on left eye crusting at the lash line, pencil eraser size lesion on bottom of lip towards the right. Mucosa was pink and hydrated. Skin turgor was normal. Cap refill was normal. Pt is alert but not verbal.

Problem

Impaired Skin Integrity

Long Term:

Clint will regain integrity of skin surface between 3^rd and 4^th toe over the next two weeks.

Nursing student will apply topical treatment at the site of skin impairment.

(Ackley, Ladwig 2008)

Client has not regained complete integrity of skin but is still being treated.

Nursing student completed a full skin assessment of patient and applied lotion to all four extremities and topical medication to the toes and legs then wrapped lower extremities with wrap and ACE bandages.

R/T

Mechanical Factors and

dry skin

Short Term:

Client will report any altered sensation or pain at site of skin impairment by the next shift.

Nursing student will determine whether the client is experiencing changes in sensation or pain.

(Ackley, Ladwig 2008)

Client showed pain by grimaces on face during the cleaning of lesions between 3^rd and 4^th toe.

Nursing student asked client if she was experiencing anything painful or uncomfortable. Pt experienced pain during the cleaning of lesions between 3^rd and 4^th toe.  Pt did not seem to experience any other pain during skin assessment or bed bath.

AEB

Lesions between toes and frail, dry skin.