Medical Surgical Nursing

jaundice and extent of edema.

11. Keep patient's fingernails short

and smooth.

12. Provide frequent skin care;

avoid use of soaps and alcohol-

based lotions.

13. Massage every 2 h with

emollients; turn every 2 h

14. Initiate use of alternating-

pressure mattress or low air loss

bed.

15. Recommend avoiding use of

harsh detergents.

16. Assess skin integrity every 4– 8

h. Instruct patient and family in

this activity.

17. Restrict sodium as prescribed.

18. Perform range of motion

exercises every 4 h; elevate

edematous extremities

whenever possible.

changes and evaluating

effectiveness of interventions

3. Prevents skin excoriation and

infection from scratching

4. Removes waste products from

skin while preventing dryness

of skin

5. Promotes mobilization of

edema

6. Minimizes prolonged pressure

on bony prominences

susceptible to breakdown

7. May decrease skin irritation

and need for scratching

8. Edematous skin and tissue

have compromised nutrient

supply and are vulnerable to

pressure and trauma

9. Minimizes edema formation

10. Promotes mobilization of

edema

 Reports relief from

pruritus

 Exhibits no skin

excoriation from

scratching

 Uses nondrying soaps and

lotions. States rationale for

use of nondrying soaps

and lotions.

 Turns self periodically.

Exhibits reduced edema of

dependent parts of the

body.

 Exhibits no areas of skin

breakdown

 Exhibits decreased edema;

normal skin turgor

Nursing Diagnosis: High risk for injury related to altered clotting mechanisms and altered level of

consciousness

Goal:Reduced risk of injury

1. Assess level of

consciousness and cognitive

level.

2. Provide safe environment

(pad side rails, remove

obstacles in room, prevent

falls).

3. Provide frequent surveillance

to orient patient and avoid

use of restraints.

4. Replace sharp objects

1. Assists in determining patient's

ability to protect self and

comply with required self-

protective actions; may detect

deterioration of hepatic

function

2. Minimizes falls and injury if

falls occur

3. Protects patient from harm

while stimulating and orienting

patient; use of restraints may

 Is oriented to time, place,

and person

 Exhibits no hallucinations,

and demonstrates no

efforts to get up unassisted

or to leave hospital

 Exhibits no ecchymoses

(bruises), cuts, or

hematoma

 Uses electric razor rather

than sharp-edged razor