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Altered Concept: Skin Integrity 94 yr. old female (Diagnostic tests: CMP,…
Altered Concept: Skin Integrity
94 yr. old female
Clinical manifestations
+2 pitting edema to BLE
fragile/dry skin
tight fitting shoes
decreased sensation to BLE
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Incontinence
No compression stockings/ted hose
blindness to right eye/wears glasses
Kypnosis
uses walker to ambulate
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Branden scale score 17
Diagnostic tests: CMP
glucose: 82
BUN: 17
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Creatinine: 0.73
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sodium: 143
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Potassium: 4.1
Chloride: 104
Calcium: 9.7
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Protein: 7.1
Albumin: 4.2
Bilirubin: 0.6
CO2: 27
Nursing interventions
Elevate BLE to reduce edema
(Potter et al, 2017 p 424)
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provide loose fitting shoes to prevent further tissue injury
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moisturize/massage BLE to promote circulation(Potter, Perry, Stockert, Hall & Ostendorf, 2017 p 455)
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monitor skin/site status for worsening edema
offer toilet Q2-3H to maintain skin clean and dry(Potter et al, 2017 p 1126)
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Perform skin assessment
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Obtain order for ted hose/measure legs
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reduce salt consumption(Mayo Clinic, 2017)
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weight daily
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encourage fluids, protein, and vegetables
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Outcomes
Patient will verbalize back to the nurse the importance of elevating her legs to reduce swelling by the end of this visit.
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Patient will be educated on the importance of position changes and hydration to maintain skin integrity and verbalize teaching back to the nurse by the end of this visit.
Patient will have no evidenced of worsening edema in the next 48 hours.
Health history
HTN
Osteoporosis
Macular degeneration
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Generalized weakness
Dry eye syndrome
Slow transit constipation
Peripheral neuropathy
Medications
Cholecalciferol 1000U/daily
Acetaminophen 500mg, BID
Aspirin 81mg daily
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Evista 60mg daily
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Calcium 200 Unit BID
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Multivitamin 1 tablet daily
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Sennosides, docusate sodium 2 tablets BID
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Propylene Glycol 0.4% eye drops BID
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Icaps MV 100mcg BID
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Amlodipine 5mg daily
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Treatments Order
Intermittent catherization
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Aquaphor lotion as needed
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No order for ted hose/compression stockings
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Pressure relieving mattress
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did not see this in patient's room.