Assessment

Nursing Diagnosis Risk for Impaired Skin Integrity r/t prolonged bed rest and altered circulation .

RATIONALE Immobility, which leads to pressure, shear, and friction, is the factor most likely to put an individual at risk for altered skin integrity. Advanced age; the normal loss of elasticity; inadequate nutrition; environmental moisture, especially from incontinence; and vascular insufficiency potentiate the effects of pressure and hasten the development of skin breakdown. Groups of persons with the highest risk for altered skin integrity are the spinal cord injured, those who are confined to bed or wheelchair for prolonged periods of time, those with edema, and those who have altered sensation that triggers the normal protective weight shifting. Pressure relief and pressure reduction devices for the prevention of skin breakdown include a wide range of surfaces, specialty beds and mattresses, and other devices. (Medical-Surgical Nursing vol. 10th ed. Brunner & Suddarths, pg 1567)

Planning After 1-2 hours of nursing intervention the client and the relatives will be able to verbalize understanding of individual factors that contribute to possibility of skin integrity impairment and take steps to correct the situation. As evidence by: understan ding the situation. patients skin remain intact no redness over bony prominen ces

Interventions

Rationale

Evaluation No. evaluation.

Objective: Dx: CVD infar ct prob. c standby O2 @ bedside c good capillary refill in 2-3 secs. c body malaise 2 weeks bedridden on CBR w/o BRP c limited ROM dry skin

Place the pt in a comfortable position Take and record vital signs

to prevent backaches or muscle aches. to note any significant changes that may be brought about by the disease Elderly patients skin is normally less elastic and has less moisture, making for higher risk of skin impairment.

Determine age.

Assess general condition of skin.

Healthy skin varies from individual to individual, but should have good turgor, feel warm and dry to the touch, be free of impairment, and have quick capillary refill (<6 seconds).

Assessment SUBJECTIVE:

Nursing Dx RATIONALE Impaired A CVD, which may verbal be caused by, communicati on hemorrhage, related to Dx Assessment Difficult Nursing RATIONALE thrombus, loss of y Subjective: CVD can be embolism or oral muscle producing Impaired caused by tone control. speech. physical an occlusion vasospasm, can in Objective: Facial mobility r/t the result in aflow. This paralysis. neuromuscular blood local Limited damage can range and Muscle area of cell death, involvement lead to O2 and facial tension of motion called infarct. It is the (client cant restless cause a lack fully notedextend caused by failure to nourish the his right able Un arm of blood supply tissues at and hold up to the then his right communicate which iscapillary level and shoulder) CVD surrounded by an that can cause patient Limited neuromuscular ability area of cells that damage w/c and difficulty are can cause secondarily to perform impaired gross motor affected. Since physical skills like symptoms depend mobility extending and lifting of the on the location of Medicalright arms the Surgical stroke and Nursing, size of the infarct, Slowed vol.2,9th Movement left it could involve edition, arm the Brunner & brains Dx: CVD Suddarths, infarct Broccas area,) page 768 prob. which is primary intubated since responsible for 4/23/10 communication FIO2- @ 23LPM TVthrough facial 320, RRexpressions and 20, PF-60 speech. By causing damage to this area, the patients communicating skills are greatly

Goals After 2 hours of nursing interventions, the client will establish method of communication in Goals which needs can be expressed. of nursing After 4 hrs intervention, the As evidence by: relatives will be able to participate in Established therapeutic regimen as evidence by: eye contact while Verbalization understanding of communicatin the situation and g therapy with others Able to Used paper participate and pen to in the interventions rendered by the express needs nurse

Intervention

Rationale

Evaluation After 2 hours of nursing intervention the goal was met the Evaluation client established method of After 4 hrsof nursing intervention, the in communication relative are able to which needs participate in are therapeutic regimen expressed as evidence by: As evidenced by : Verbalization understanding of Established the situation and therapy eye contact Able to while participate communicatin in the interventions rendered by the g with others nurse Used paper and pen to express needs

Intervention

Rationale

>Monitored vital signs with emphasis to BP.

>Establishes baseline data for review of existing

conditions. Independent: Independent: Determine To degree of establish >Provided an Immobility compara tive atmosphere of >Impaired ability baseline acceptance and to communicate Observe To note movement any privacy through spontaneously is when client is incongru speaking slowly frustrating and unaware ence with the and in a normal embarrassing. reports tone, not forcing Nursing actions of abilities the client to should focus on Support Reduce communicate. decreasing the affected part risk of tension and with pillows pressure ulcers conveying an Give rest To help understanding of periods to reduce Activities fatigue how difficult the and O2 situation must be demand Encourage for client the energy adequate producti >Taught fluids and right on diet techniques to as necessary to (Nursing Care improve speech >Deliberate the Plan, 6th client edition, by initially asking actions can be Gulanick/Myers questions that taken879) pg. to improve client can answer speech. As the with a yes or no. clients speech improves, his confidence will

AEJEL ASAA GROUP- B20