Assessment | Diagnosis | Planning | Intervention | Rationale | Evaluation |
Objective: >increase body temperature of 37.8C >flushed skin >warm to touch >decrease elasticity of the skin >dry skin >delayed capillary refill of four seconds >afebrile | >Impaired skin integrity related to altered body temperature | >At the end of the shift the patients’ capillary refill must be less than 4 seconds. | >Encouraged implementation and posting of a turning schedule, restricting time in one position to 2 hours or less >Encouraged the SO to maintain functional body alignment of the patient like positioning it properly. >Assessed the patients ability to move >Encouraged adequate hydration and nutrition >Clean, dry and moisture skin especially bony prominences | >To prevent discomfort and injuries to the body; to promote circulation >Misalignment can lead to discomforts and injuries to joints, nerves or limbs. >Immobility is greater risk factor in skin breakdown >Adequate hydration and nutrition helps maintain skin turgor, and suppleness. >Smooth and supple kin is more resistant to injury. | Goal met as manifested by decreased in patient’s capillary refill from 4 secs. - 3 secs. |
Categories:
Nursing Care Plan