Date September 9, 2010 @ 7-3 shift

Cues Subjective: Naunsa naman intawon ning akong pamanit labaw na sa katiilan nko, katolkatol pa jud, as verbalized by the patient. Objectives: Dry Skin Noted Skin Turgor Noted Scratching Of Skin Noted

Needs
N U T R I T I O N A L M E T A B O L I C P A T T E R N

Nursing Diagnosis Risk for impaired skin integrity related to alterations in skin turgor due to edema secondary to CRF.

Planning Within four hours of nursing care, patient will be able to demonstrate behaviors/ techniques to prevent skin breakdown/injur y.

Nursing Intervention 1. Monitor VS. Rationale: To obtain baseline data. 2. Inspect skin for changes in color, turgor, and vascularity. Note redness and excoriation. Rationale: Indicate areas of poor circulation/breakdown that may lead to decubitus formation/infection. 3. Monitor fluid intake and hydration of skin and mucous membranes. Rationale: Detects presence of dehydration or overhydration that affects circulation and tissue integrity at the cellular level. 4. Inspect dependent areas for edema. Elevate legs as indicated. Rationale: Decrease pressure on edematous, poorly perfused tissues to reduce ischemia. 5. Change position frequently, move patient carefully, pad bony prominences and place elbow/heel protectors. Rationale: To prevent pressure sores.

Evaluation GOAL MET. After four hours of nursing care, the patient was able to demonstrate behaviors/techniqu es to prevent skin breakdown/injury.

Scientific Basis: Skin is the primary defense of the body; it protects the body against infections and diseases brought about by the invasion of microbes in the body. A normal skin is moist and intact; dryness of the skin is more prone to friction that may result to impairment of the skin integrity as compared with a moist skin.

6. Provide soothing skin care. Restrict use of soaps. Apply ointments or creams. Rationale: Decreases itching and relief of dry, cracked skin. 7. Keep linens dry and wrinkle-free. Rationale: Reduces derma irritation and risk of skin breakdown. 8. Investigate reports of itching. Rationale: Itching can occur because the skin is an excretory route for waste products. 9. Recommend patient use cool moist compresses to apply pressure on pruritic areas. Keep fingernails short and encourage use of gloves during sleep if needed. Rationale: Alleviates discomfort and reduces risk of dermal injury. 10. Suggest wearing loose-fitting cotton garments. Rationale: Prevents direct dermal irritation and promotes evaporation of moisture on the skin.