ASSESSMENT PATHOPHYSIOLOGY OBJECTIVE INTERVENTION RATIONALE EXPECTED OUTCOME

P- impaired skin LTO: After 24hours of Dx> Inspected skin for >Indicates areas of poor LTO: After 24 hours of
integrity nursing intervention the changes in color, turgor, circulation/ breakdown nursing intervention the
S> the patient’s skin will be vascularity. Note that may lead to goal will be fully met if
O> maintained intact. redness excoriation. infection. the patient’s skin will be
Observe for echymosis, maintained intact.
purpura.

>Monitored fluid intake >Detects presence of

and hydration of skin dehydration or
and mucous overdehydration that
Nsg. Dx.> Risk for membranes. affects circulation and
impaired integrity r/t tissue integrity at the
alteration in skin cellular level.
turgor(edema)
>Inspected dependent >Edematous tissue are
areas for edema. more prone to
breakdown.

Tx> Elevated legs as >Elevation promotes

indicated. venous return, limiting
venous edema
formation.

>Changed position >Decrease pressure on

frequently; move edematous, poorly
patient carefully. perfuse tissue to reduce
ischemia.

>Kept linens dry, wrinkle >Reduces dermal

free. irritation and risk for
skin breakdown.

Edx>Recommended >Alleviates discomfort

patient use of cool, and reduces risk for
moist compress to apply dermal injury.
pressure pruritic areas
and keep fingernails
short.

>Suggested to wear >Prevents direct dermal

loose fitting garments. irritation and promotes
evaporation of moisture
on the skin.

>Encouraged patient to >To know nature of

verbalize feelings and problem.
concerns.