ASSESSMENT EXPLANATION OF OBJECTIVES NURSING RATIONALE EVALUATION

THE PROBLEM INTERVENTION

Objective: Pressure, shear, and STO: Dx: Assessment of the STO:
Weight 3.5kg friction from After 8 hours of Assess patient’s condition of the After 12 hours of
Vomiting immobility put an nursing intervention, nutritional status, nursing intervention,
skin provides
Weak body individual at risk for the patient will the patient will able
including weight, baseline data for
altered skin integrity. -identify individual to identify individual
Nursing diagnosis: Other factors that weight loss, and possible
risk factors. risk factors, and he
Risk for impaired hasten skin serum albumin interventions for
-verbalize can also participate
skin integrity related breakdown include
understanding of levels. the nursing to level of ability to
to malnourishment. age, the normal loss diagnosis Risk for
treatment needs. prevent skin
of elasticity,
-participate to level Assess for edema. Impaired Skin breakdown and
inadequate nutrition,
environmental of ability to prevent Integrity. maintain correct
moisture, and skin breakdown. body growth.
vascular LTO: Tx: Specific areas LTO:
insufficiency. Special After weeks nursing Provide gentle where skin is After 24 hours
beds, mattresses, and intervention, the massage around nursing intervention,
stretched tautly
other useful devices client will not exhibit reddened or the person will
are at higher risk
provide pressure signs of bedsore. Can blanched areas. develop and maintain
relief and pressure also develop body for breakdown skin and body
redistribution. growth. Ex: because the growth.
Encourage adequate possibility of
nutrition and ischemia to skin is
hydration: high as a result of
  compression of
 2000 to 3000
skin capillaries
kcal/day
between a hard
(more if
increased surface (e.g.,
metabolic mattress, chair, or
demands) table) and the
 Fluid intake bone. For light
of 2000 pigmented skin,
mL/day pressure areas
unless
appear to be red.
medically
For darker skin
restricted.
tones, these areas
appear to be red,
blue, or purple
hue spots.