Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective: >Impaired skin >At the end of the shift >Encouraged >To prevent discomfort and Goal met as
>increase body integrity related to the patients’ capillary implementation and posting injuries to the body; to manifested by
temperature of altered body refill must be less than 4 of a turning schedule, promote circulation decreased in
37.8C temperature seconds. restricting time in one patient’s capillary
>flushed skin position to 2 hours or less refill from 4 secs. - 3
>warm to touch secs.
>decrease elasticity >Encouraged the SO to >Misalignment can lead to
of the skin maintain functional body discomforts and injuries to
>dry skin alignment of the patient like joints, nerves or limbs.
>delayed capillary positioning it properly.
refill of four seconds
>afebrile >Assessed the patients >Immobility is greater risk
ability to move factor in skin breakdown

>Encouraged adequate >Adequate hydration and

hydration and nutrition nutrition helps maintain skin
turgor, and suppleness.

>Clean, dry and moisture >Smooth and supple kin is

skin especially bony more resistant to injury.
prominences