Assessment SUBJECTIVE: Namamanas ang kamay at paa ko as verbalized by the patient Objective:

Diagnosis Risk for skin integrity related to alterations in skin turgor (edema)

Planning After 8 hours of nursing intervention Patient will maintain an intact skin

Intervention -inspect skin for changes in colour, turgor, vascularity, note redness -monitor fluid intake and hydration of skin and mucous membranes

Rationale --indicates areas of poor circulation/break down that may lead to infection -detects presence of dehydration or over hydration that affect circulation and tissue integrity at the cellular level

Evaluation After the nursing intervention was done the patient maintain an intact skin

-inspect dependent areas for edema. Elevate legs as indicate

-edematous tissues are prone to breakdown. Elevation promotes venous return, limiting venous stasis, edema formation -prevents direct dermal irritation and promotes evaporation of moisture on the skin -lotions and ointment may be desired to relieve dry, cracked skin

-suggest wearing loose fitting cotton garments

-Apply creams or ointments as prescribed