"Assessment Nursing Goals/Expected Intervention and Scientific Rationale EvaluationProblem Pt OutcomesSubjective data: Impaired Skin Within 2 weeksPt will be turned every two hours as By the end of day 7 there is reduced redness over the Decreased Integrity related No itching or skin evidence by nursing documentation sacral areamobility (bed to malnutrition dryness Conduct a full skin inspection twice daily No new skin breakdown is recordedbound) and pressure Good skin paying close attention to the skin directly No other areas of pain or discomfort are reported.Decreased oral ulcers as hygiene over bony prominences Other pressure points remain intact.intakeevidence by Clean intact skin Regularly check for moist areas - Pt’s wounds will be kept clean and free from any further disruption of Pressure relief by determine the cause of moisture and aim infection. epidermal position changes to reduce theAdequate oral intake as toleratedObjective data: tissues. and special amount on the skinWt loss 5kg in mattress. Pt’s wounds will be changed daily perpast weekwound care orders and proper handSmall pressure hygiene will be performed before andulcer (0.2 x after dressing changes.0.1cm) on his Administer medications for stomatitis assacrum.orderedInadequate Soft dietnutritional intake 2 – 4 hrly mouth careOral mucosal SCIENTIFIC RATIONALE: (#NOTEstomatitis REFERENCES) A pressure ulcer is an injury to the skin asa result of constant pressure due toimpaired mobility. The pressure result inreduced blood flow and eventuallycauses cell death, skin breakdown, andthe development of an open wound.Pressure ulcers can occur in persons whoare wheelchair-bound or bed-bound,sometimes even after a short time (2 to 6 hours).(Brown & Edwards, 2012, p.239)Malnutrition can cause increasedinfection, electrolyte imbalances, alteredskin integrity, anaemia, weakness, andfatigue (Furman, 2006).Poor dentition can cause difficulty withchewing food and swallowing, leading toa decrease in nutrient intake.( Maher etal, 2010, p.42 ) "