Nursing Diagnosis Risk for impaired skin integrity> related to pitting edema.
Expected outcomes:
clients can demonstrate behaviors / techniques to prevent skin damage.
Maintaining the integrity of the skin.
Interventions:
1. Change position often in bed / chair, assistive range of motion exercises passive / active.
2. Provide frequent skin care, minimizing the moisture / excretion.
3. Check narrow shoes / sandals and change as needed.
4. Monitor skin, bone protrusion noted, edema, impaired circulation area / pigmentation or overweight / underweight.
5. Massage the area red or white.
Rational:
1. Improving circulation / lowering an area that interfere with blood flow.
2. Too dry or moist skin damage and accelerating damage.
3. Dependent edema can cause the shoe is too narrow, increasing the risk of stress and damage to the skin on the feet.
4. Lowering the pressure on the skin, improve circulation.
5. Skin disorders are at risk due to the peripheral circulation, physical immobilization and impaired nutritional status. Increase blood flow, minimizing tissue hypoxia.
Expected outcomes:
clients can demonstrate behaviors / techniques to prevent skin damage.
Maintaining the integrity of the skin.
Interventions:
1. Change position often in bed / chair, assistive range of motion exercises passive / active.
2. Provide frequent skin care, minimizing the moisture / excretion.
3. Check narrow shoes / sandals and change as needed.
4. Monitor skin, bone protrusion noted, edema, impaired circulation area / pigmentation or overweight / underweight.
5. Massage the area red or white.
Rational:
1. Improving circulation / lowering an area that interfere with blood flow.
2. Too dry or moist skin damage and accelerating damage.
3. Dependent edema can cause the shoe is too narrow, increasing the risk of stress and damage to the skin on the feet.
4. Lowering the pressure on the skin, improve circulation.
5. Skin disorders are at risk due to the peripheral circulation, physical immobilization and impaired nutritional status. Increase blood flow, minimizing tissue hypoxia.
Source :
http://list-nanda-nursing-diagnosis.blogspot.com/2013/01/risk-for-impaired-skin-integrity-ncp.html