Nursing Diagnosis: High Risk for Impaired Skin Integrity r/t prolong bed rest, presence of edema 2º CHF

Cause analysis: Dependent edema is one of the early manifestations of CHF. Venus congestion in the peripheral vascular
beds. Causes hydrostatic capillary pressure. Capillary hydrostatic pressure overwhelms the opposing pressure of plasma
proteins and fluid shifts out of the capillary beds and into the interstitial spaces, with resultant pitting edema. (Med-Surg by
Black & Hawks . 1656) Edematous areas specially in the sacral area is at risk for the formation of ulcer.(Med-Surg by Porth)
Decreased ability to move increases the injury to the skin. (Med-Surg by Black & Hawks p. 2127)
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective STO Assessment: STE
SO Within the shift pt Closely asses skin for any To monitor any abnormalities Within the shift pt
verbalized,”sige will participate in alterations. for early treatment. was able to change
lang man na siya positioning and position q 2-3hours.
gahigda, turning at least q 2 Independent:
makabakod lang hours. Provide adequate To prevent vasoconstriction.
na siya kung clothing/covers; protect
pugson. Init na from drafts.
gain kaayo na
iyang likod. Limit/avoid use of plastic Moisture potentiates skin
materials (e.g., rubber breakdown.
sheet, plastic backed
Objective LTO linen savers). Remove LTE
♦ Poor nutrition Within 3 days pt will wet, wrinkled linens To enhance understanding and Within 3 days of
♦ Poor skin maintain intact skin promptly. cooperation. care, pt did not
turgor and absence of develop any
♦ Dry skin pressure ulcer on Develop repositioning To reduce pressure pressure ulcers.
♦ Facial edema the edematous schedule for client, on/enhance circulation to However, pt died
♦ Bipedal pitting area. involving client in reasons compromise tissues. on the 3rd day.
edema +3 for and decisions about
times and positions in
♦ Prolonged
conjunction with other
capillary refill
activities.
time >3 sec
Use appropriate padding To reduce pressure
devices when indicated
(e.g., pillows)
 CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Provide optimum nutrition To provide a positive
and increased protein intake. nitrogen balance to aid in
healing and to maintain
general good health.

Collaborative
Collaborate with the dietary
department to provide high
protein, high calorie, and low
fat and low salt diet.
Reference: NCP by Neal p. 275-276
Inadequate nutrition causes
collagen to stiffen, elastic
fibers to degenerate, and
the amount of
subcutaneous tissue to
decrease.