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Impaired Skin Integrity Related To Excess Fluids Volume As Evidenced by Swelling of The Lower Extremities

The patient presented with swelling of the lower extremities and difficulty ambulating. Examination revealed +3 edema, shiny skin, elevated vital signs, and lab results consistent with fluid overload. The diagnosis was impaired skin integrity related to excess fluid volume. The plan was to monitor intake/output, assess for signs of infection or respiratory distress, place the patient in a Fowler's position, and limit sodium intake per the physician. The goals of care were met through nursing interventions to reduce swelling and normalize vital signs.

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Levin Menpin
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92 views

Impaired Skin Integrity Related To Excess Fluids Volume As Evidenced by Swelling of The Lower Extremities

The patient presented with swelling of the lower extremities and difficulty ambulating. Examination revealed +3 edema, shiny skin, elevated vital signs, and lab results consistent with fluid overload. The diagnosis was impaired skin integrity related to excess fluid volume. The plan was to monitor intake/output, assess for signs of infection or respiratory distress, place the patient in a Fowler's position, and limit sodium intake per the physician. The goals of care were met through nursing interventions to reduce swelling and normalize vital signs.

Uploaded by

Levin Menpin
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NAME: Levin C.

Menpin DATE: November 23, 2022


CLINICAL INSTRUCTOR: SCORE: _______________________

ASSESSMENT DIAGNOSIS ANALYSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION


Impaired skin The edema or swelling of the
SUBJECTIVE: integrity related lower extremities is the result Short-term: After 3 hour of nursing Independent:
“ Namamaga yung paa to excess fluids of the fluids having to move intervention patient vital sign will be 1. Monitor the Input 1. To know if the input GOAL MET. Monitored the
ko at hirap ako makalad volume as from the intravascular to in the normal range. and output of the and output of the input and out of the patient
pero tinutulungan ako evidenced by interstitial space leading the patient and limit patient is imabalance and abide by limitating the
ng kapatid ko pag gusto cappilaries to leak fluid and the fluid intake of because having fluid intake of the patient.
swelling of the
ko umupo , medyo causing swelling (edema) to the patient imbalanced I&O may
lower extremities
mahirap nga lang.” as happen further more result in Long-term: After 3-5 days of nursing indicate renal
verbalized by the decreased skin integrity . intervention the swelling of legs will problems.
patient be decreased and the Vital signs stays
in normal ranges.
OBJECTIVE: 2. Monitor the Vital 2. To detect for early GOAL MET. Monitored the
● +3 edema signs of the signs of infection, patients vital signs q4.
patient respiratory distress
● Stretched , shiny and to know the
skin. status of the patient.
● Vital Signs
GOAL MET. Assessed the
o BP 140/110 3. Assess the patient 3. Assess if the patient is patient respiratory pattern .
mmHg respiratory in respiratory distress
pattern. because having excess
o RR:20 of fluid volume may
cause pulmonary
o O2: 95% edema.
o PR: 70 bpm GOAL MET. Patient is
4. Place the patient 4. This helps the patient
in a fowler’s or in breathing placed in a fowlers position.
o Tempt: 65.5
high-fowlers comfortably.
C
position
● Lab Test

o Hemoglbin:
11.3

o Hematocrit:
35.4 Dependent: GOAL MET.Patient was
1. Limit sodium as 1. Sodium cause fluid able to abide and limit her
prescribed by the retention and sodium intake.
physician restricting/ limiting
physician. sodium will aid in
decreasing fluid
retention .

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