Medical Diagnosis: Spinal Tumor & Injury (T5-T7)

ASSESSMENT DIAGNOSIS PLAN INTERVENTION RATIONALE EVALUATION

S> his mother Risk for impaired Goal: Diagnostic:

verbalized, skin integrity After the nursing
“ Hindi na related to altered intervention, the 1. Inspect all skin areas, 1. Skin is especially prone to 1. Was the client able to
niya peripheral patient will be noting capillary breakdown because of identify risk factors of
nagagalaw circulation able to prevent blanching/refill, redness, changes in peripheral acquiring impaired skin
paa niya. secondary to altered skin sweating. circulation, inability to integrity?
Hindi na spinal cord injury integrity. sense pressure, __yes __no
niya rin immobility, and altered
nakakaram Rationale: Objectives: temperature regulation. 2. Was the client able to
dam. Basta Patient with After 3 days of utilize the preventive
yung mula spinal cord injury nursing 2. Monitor client’s response 2. Monitoring the client’s measures to maintain
sa tiyan or tumor has intervention, the to nursing intervention. response can help good skin integrity?
pababa sa loss sensation client will: evaluate the effectiveness __yes__no
paa.” below the level of the nursing intervention.
> his mother of lesion, there is a) Identify risk 3. Was the client able to
stated, “May an ever-present, factors of Therapeutic: verbalize understanding
tumor kasi sa life-threathening acquiring about the importance of
spinal cord niya risk of of impaired skin 3. Turn and position q 2 3. This optimizes circulation interventions?
kaya ayun” pressure ulcers. integrity hours or as needed of all tissues and __yes__no
iN areas of local decreases pressure)
O> dry, scaly tissue ischemia, b) Use
skin noted on where there is preventive 4. Wash and dry skin, 4. Clean, dry skin is less
lower continuous measures to especially in high moisture prone to
extrimities pressure and maintain good areas such as perineum. excoriation/breakdown.
> no noted where the skin integrity
capillary refill peripheral 5. Keep bedclothes dry and 5. Reduce or prevents skin
(blanching) on circulation is c) Verbalize free of wrinkles, crumbs. irritation.
lower inadequate, understanding
extrimities pressure ulcers of necessary H. Teaching:
 > lost of can develop. the
sensory Prolonged interventions. 6. Teach the patient the 6. Increase client’s
perception on immobilization of rationale of the planned compliance, and decrease
lower the patient interventions risk of skin breakdown
extrimities increases the
risk of pressure
ulcers.

Reference:
Medical surgical
nursing (Brunner
and
Suddarth’s) , 10th
Edition