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).

AEJEL ASAA GROUP- B20

Assessment Subjective: Objective: Limited range of motion (client cant fully extend his right arm and hold up his right shoulder) Limited ability and difficulty to perform gross motor skills like extending and lifting of the right arms Slowed Movement left arm Dx: CVD infarct Nursing Dx Impaired physical mobility r/t neuromuscular damage involvement RATIONALE CVD can be caused by an occlusion in the blood flow. This can lead to O2 and the cause failure to nourish the tissues at the capillary level and that can cause neuromuscular damage w/c can cause impaired physical mobility MedicalSurgical Nursing, vol.2,9th edition, Brunner & Suddarths, Goals After 4 hrs of nursing intervention, the relatives will be able to participate in therapeutic regimen as evidence by: Verbalization understanding of the situation and therapy Able to participate in the interventions rendered by the nurse Intervention Rationale Evaluation After 4 hrs of nursing intervention, the relative are able to participate in therapeutic regimen as evidence by: Verbalization understanding of the situation and therapy Able to participate in the interventions rendered by the nurse

Independent: Determine degree of Immobility Observe movement when client is unaware

Support affected part with pillows Give rest periods to Activities

Independent: To establish compara tive baseline To note any incongru ence with the reports of abilities Reduce risk of pressure ulcers To help reduce

prob. intubated since 4/23/10 FIO2- @ 23LPM TV320, RR20, PF-60

page 768 ) Encourage adequate fluids and right diet as necessary to the client

fatigue and O2 demand energy producti on (Nursing Care Plan, 6th edition, Gulanick/Myers pg. 879)

Assessment SUBJECTIVE:

Difficulty producing speech. Facial paralysis. Muscle and facial tension restless noted Un able to communicate CVD patient

Nursing Dx Impaired verbal communicati on related to loss of oral muscle tone control.

RATIONALE A CVD, which may be caused by, hemorrhage, thrombus, embolism or vasospasm, can result in a local area of cell death, called infarct. It is caused by a lack of blood supply which is then surrounded by an area of cells that are secondarily affected. Since symptoms depend

Goals After 2 hours of nursing interventions, the client will establish method of communication in which needs can be expressed. As evidence by: Established eye contact while communicating with others Used paper and pen to express needs

Intervention

Rationale

Evaluation After 2 hours of nursing intervention the goal was met the client established method of

>Monitored vital signs with emphasis to BP.

>Establishes baseline data for review of existing conditions.

communication in which needs are expressed As evidenced by : Established eye contact while communicatin g with others Used paper and pen to

>Provided an atmosphere of acceptance and privacy through speaking slowly and in a normal tone, not forcing >Impaired ability to communicate spontaneously is frustrating and embarrassing. Nursing actions

on the location of the stroke and size of the infarct, it could involve the brains Broccas area, which is primary responsible for communication through facial expressions and speech. By causing damage to this area, the patients communicating skills are greatly altered and affected.

the client to communicate.

should focus on decreasing the tension and conveying an understanding of how difficult the situation must be for the client

express needs

>Taught techniques to improve speech by initially asking questions that client can answer with a yes or no. >Deliberate actions can be taken to improve speech. As the clients speech improves, his confidence will increase and she will make more attempts at >Used strategies speaking. >Improving the clients comprehension can help to decrease frustration and increase trust. Clients with aphasia can

(Medical- Surgical Nursing, vol.2,9th edition, Brunner & Suddarths, page 1259 )

to improve the clients comprehension by using touch and behavior to communicate calmness and adding other non

 verbal methods of communication such as pointing or using flash cards for basic needs; using pantomime; or using paper and pen. >Involved the significant others in the plan of care.

correctly interpret tone of voice.

>Enhances participation and commitment to plan.

>Imparts thought >Educated relatives to establish a method of communication through sign language. and answers the needs of the client with lessened difficulty. (Nursing Care Plan, 6th edition, Gulanick/Myers pg. 565)