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Subjective:
Pt demonstrated discomfort through grimacing
and the tightening of her muscles during a BM clean up.
Objective:
Pt is physically immobile and unable to get out of bed.
An area on the pt’s buttocks was reddened and warm to touch.
Pt is incontinent of her bowels, which leads to moisture on her skin.
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Problem:
Risk for impaired skin integrity
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Long Term:
Pt will verbalize the measures needed to promote
good skin integrity by discharge.
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*Educate pt on the importance of proper
dieting and food intake.
Rationale:
“… Nutrition is fundamental to normal
cellular integrity and tissue repair.” (Potter and Perry, 2008, p. 1310)
*Educate the pt on the importance of keeping the skin clean and dry.
Rationale:
“Moisture softens the skin and causes a break
in the skin integrity.”
(Potter & Perry, 2009, p. 1302)
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I
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Unable to evaluate goal due to pt’s confusion. Hypothetically, once the patient was
oriented, she would be taught the needed measures to promote good skin integrity
and she would verbalize her understanding.
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Unable to evaluate interventions due to pt’s confusion. Hypothetically, once the
pt was oriented, she would be taught the appropriate interventions needed to prevent
skin breakdown and promote good skin integrity.
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R/T
Immobility
Mechanical factors (shearing, friction)
Moisture
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Short Term:
Pt will not develop any further skin breakdown
during her stay at the facility.
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*Reposition the pt at least once every two hours.
Rationale:
“Positioning interventions reduce pressure and
shearing force to the skin.” (Potter & Perry, 2009, p. 1305)
*Keep the skin clean and dry
Rationale:
“Moisture softens the skin and causes a break
in the skin integrity.”
(Potter & Perry, 2009, p. 1302)
*Monitor skin condition at least once a day
for color or texture changes, dermatological conditions, or lesions.”
Rationale: “Systematic inspection can identify
impending problems early.” (Ackley & Ladwig, 2008, p. 754)
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I
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Goal met. Pt’s skin has no signs of worsening
or advanced impairment.
Pt’s skin integrity has not been further compromised.
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Continue interventions as listed. Reposition
the pt at least once every two hours. Continue to keep the pt’s skin clean and dry.
Continue to monitor the skin for any signs of change or breakdown.
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