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NCP - Edema

The patient was experiencing numbness and pain in their hands and feet. The nurse diagnosed skin integrity issues related to changes in skin temperature, edema, and circulation. Over the next few hours, the nurse would inspect the patient's skin for changes in color, temperature, circulation, and note any redness. The nurse would also monitor the patient's fluid intake and hydration of their skin and mucous membranes. After the nursing intervention, the patient maintained intact skin.

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1K views1 page

NCP - Edema

The patient was experiencing numbness and pain in their hands and feet. The nurse diagnosed skin integrity issues related to changes in skin temperature, edema, and circulation. Over the next few hours, the nurse would inspect the patient's skin for changes in color, temperature, circulation, and note any redness. The nurse would also monitor the patient's fluid intake and hydration of their skin and mucous membranes. After the nursing intervention, the patient maintained intact skin.

Uploaded by

vipncpusers
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
Download as doc, pdf, or txt
Download as doc, pdf, or txt
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Assessment SUBJECTIVE: Namamanas ang kamay at paa ko as verbalized by the patient b!

e"tive:

Diagnosis #isk $or skin integrity related to alterations in skin t%rgor &edema'

Planning ($ter ) ho%rs o$ n%rsing intervention *atient +ill maintain an inta"t skin

Intervention ,inspe"t skin $or "hanges in "olo%rt%rgor- vas"%laritynote redness ,monitor $l%id intake and hydration o$ skin and m%"o%s membranes

Rationale ,,indi"ates areas o$ poor "ir"%lation/breakdo +n that may lead to in$e"tion ,dete"ts presen"e o$ dehydration or over hydration that a$$e"t "ir"%lation and tiss%e integrity at the "ell%lar level

Evaluation ($ter the n%rsing intervention +as done the patient maintain an inta"t skin

,inspe"t dependent areas $or edema. Elevate legs as indi"ate

,edemato%s tiss%es are prone to breakdo+n. Elevation promotes veno%s ret%rn- limiting veno%s stasis- edema $ormation ,prevents dire"t dermal irritation and promotes evaporation o$ moist%re on the skin ,lotions and ointment may be desired to relieve dry"ra"ked skin

,s%ggest +earing loose $itting "otton garments

,(pply "reams or ointments as pres"ribed

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