Impaired Skin Integrity related to mobilization, uremia, capillary fragility and edema.
Purpose: The client no disturbance / change the integrity of the skin during treatment.
Interventions:
Rationale:
Risk for Excess Fluid Volume - Glomerulonephritis Care Plan
Risk for Infection - Glomerulonephritis Care Plan
Activity Intolerance - Glomerulonephritis Care Plan
Purpose: The client no disturbance / change the integrity of the skin during treatment.
Interventions:
- Assess the skin from redness, damage, bruises, turgor and temperature.
- Keep skin dry and clean. Clean and dry perineal area after defecation.
- Treat the skin by using lotion to prevent dryness of the area pruritus.
- Avoid using harsh soaps and rough on the skin of the client.
- Encourage the client to not scratch the area pruritus.
- Encourage the client to ambulation, as much as the client.
- Help the client to change position every 2 hours if the client bedrest. Maintain a crease-free linen. Give protection on the heel and elbow.
- Remove clothing, jewelry that can cause obstructed circulation.
- Note the edema area with caution.
- Maintain adequate nutrition.
Rationale:
- Anticipating the damage to the skin so that it can be given treatment.
- Skin that is dry and clean is not easy irritation and reduce bacteria growth media.
- Lotion can lather that is not easily broken / damaged.
- Harsh soaps can cause skin dryness and harsh soaps can scratch the skin.
- Scratching cause skin damage.
- Ambulation and change of position improves circulation and prevents the emphasis on one side.
- Folds bed linen cause pressure on the skin.
- Circulation is impeded facilitate the occurrence of skin damage.
- Skin elasticity area of edema is very less, so easily damaged.
- Adequate nutrition increases skin defense.
Risk for Excess Fluid Volume - Glomerulonephritis Care Plan
Risk for Infection - Glomerulonephritis Care Plan
Activity Intolerance - Glomerulonephritis Care Plan
