Web21 de abr. de 2015 · Goal is attainable, patient was taught techniques to keep skin dry. Goal is realistic, client is awake, alert, and oriented and ready to learn techniques to protect skin from moisture. Goal is time-bound, client will describe the three measures to protect the skin from moisture by 1200 on 4/15. LT: Revisions not needed. Web14 de mar. de 2024 · Encourage daily moisturization and prevention of hot water use. Hot water can cause drying of the skin which may impair the skin integrity further. Moisturization can prevent this. Nursing Plan 5 – Edema formation. Diagnosis: Malnourished patient with Kawasaki disease showing bilateral swelling of feet.
Skin Integrity Guidelines Risk Factors/Goals Potential ... - Indiana
Web18 de abr. de 2015 · brittleigh. 13 Posts. Apr 19, 2015. One short term goal for impaired skin integrity is good nutritional intake because this helps the wound heal faster. Another short term goal is adequate fluid intake because like nutrition, this aids in healing. Just think of simple goals like that! Webc. The patient has a raised red rash on the right shin. d. The patient's capillary refill is less than 2 seconds. A. 4. The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. greater illusion dnd 5e
NCP - Impaired Skin Integrity PDF Wound Dietary …
Web3. Patient demonstrates understanding of plan to improve current skin status by end of shift. Long Term Goal 1. Patient demonstrates behaviors/techniques to prevent skin breakdowns and to maintain skin integrity by 2 weeks. Nursing Interventions/ Rationales Medical Dx/ Reason for Admission/history/Age Signs and Symptoms Outcomes Evaluation 1. WebGOAL: Monitor the condition of skin and risk factors to ensure skin integrity Potential Interventions: Inspect skin daily with cares (done by nursing assistants) Inspect skin … WebSuspected Deep tissue injury: – Skin is intact; appears purple or maroon. – Blood filled tissue due to underlying tissue damage. – Affected area may have felt firm, boggy, … flink window assigner