Nursing Diagnosis

NURSING DIAGNOSIS | RATIONALE | NURSING INTERVENTIONS | RATIONALE | EVALUATION | February 21, 20132pm-10pmImpaired skin integrity related to vehicular accident as evidenced by abrasions.Objective:-abrasions on face, both arms, and left legGoal:After 6 hours of nursing intervention, patient will be able to display timely healing of skin lesions without complication. | Altered epidermis or dermis.Vehicular Accident direct trauma to the skinabrasions of extremities and swelling of the skin in upper eyelidImpaired skin integrity | 1. Assess skin daily. Note color, turgor, circulation and sensation. Describe or measure lesions and observe changes2. Maintain good skin hygiene, wash thoroughly, pat dry carefully, and gently massage with lotion or appropriate cream3. Maintain clean, dry, wrinkle free linen, preferably soft cotton fabric4. File nails regularly5. Observe skin on daily basis describing changes6. Apply topical or systemic drugs as indicated7. Keep the area clean or dry carefully dress wounds, support incision, prevent infection, manage incontinence, and stimulate circulation to surrounding areas | -establishes comparative baseline providing opportunity for timely intervention-maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to dry or fragile skin. Massaging increases circulation to the skin and promotes comfort-skin friction cause by wet or wrinkled or rough sheets leads to irritation of fragile skin and increases risk for infection-long or rough nails increase risk of dermal damage-to allow for early intervention-to treat skin abrasions-assist body’s natural process of repair. | Goal partially met.Patient was able to display timely healing of skin without complication. |

NURSING DIAGNOSIS | RATIONALE | NURSING INTERVENTIONS | RATIONALE | EVALUATION | February 21, 20132pm-10pmImpaired physical mobility related to pain as evidenced by mandibular fracture and abrasions on