Date/ Time A U G U S T 19, 2010 3PM

RISK FOR IMPAIRED SKIN Cues INTEGRITY Nursing Need

Subjective: ingon si doc na mau lang ng hupong ko kay nagdaku daw akong heart tong jan as verbalized by the patient Objective: Good skin turgor No edema noted Palor noted CRT of greater than 2 seconds N U T R I T I O N A L M E T A B O L O C P A T T E R N Diagnosis Risk for impaired skin integrity related to altered circulation secondary to right sided hypertrophy a manifestation of right ventricular hypertrophy is edema. Groups of persons with the highest risk for altered skin integrity are those with edema.

Objectives After 8 hours span of care, my patient will be able to maintain skin integrity, as manifested by: 1. Good skin turgor 2. No edema noted 3. Maintai n vital signs within the normal range (BP:110/7 0-130/90; CR: 7090; RR: 16-20; T: 25.8-37.5)

Nursing Intervention 1. Maintain strict skin hygiene to maintain skin integrity at optimal level 2. Change position in bed on a regular schedule prevent pressure sores 3. Provide adequate clothing prevent vasoconstriction 4. Provide protection by use of pillow increase circulation and eliminate excessive tissue pressure 5. Observe for reddened areas reduces likelihood of progression to skin breakdown 6. Emphasize importance of adequate fluid intake maintain good health and skin turgor 7. Recommend continuation of regular exercise program enhance circulation 8. Suggest use of lotions decrease irritable itching 9. Recommend elevation of lower extremities when sitting enhance venous return and reduce edema formation

Evaluation August 19, 2010 11PM GOAL PARTIALLY MET! After 8 hours span of care, my patient was able to maintain skin integrity as manifested by: 1. Good skin turgor 2. No edema on extremities 3. BP: 120/60; CR: 65; T: 35.6; RR: 22

90